Documenting a Spravato session step-by-step

Spravato (esketamine) sessions are one of the highest-stakes documentation events in outpatient psychiatry. The visit takes two hours. It involves controlled-substance handling, REMS attestations, vitals at multiple points, and a 2-hour observation period that has to be charted accurately. Payers audit Spravato claims at a higher rate than almost any other psychiatric service. Documentation defects are the most common cause of denial.

This guide walks through the full session, what belongs in the note, and what each section is doing. A working Nextvisit template that follows this structure is available in the template library at /templates.

Pre-session

The pre-session block establishes that the patient is eligible for treatment today. The note should document four things.

First, REMS attestation: the patient is enrolled in the Spravato REMS, the prescriber is REMS-certified, and the dispensing pharmacy is REMS-certified. Most practices have this as a checkbox on the form, but it should appear in the note text as well so it is searchable on audit.

Second, indication: treatment-resistant depression with adequate trial documentation, or major depressive disorder with acute suicidal ideation per the FDA label. The note should reference the clinical assessment that supports the indication, not just state it.

Third, current medications: full active medication list at session start, including any antidepressant the patient is required to be on per the indication, with dose and adherence.

Fourth, baseline vitals: blood pressure, heart rate, and any pre-session screening measures (PHQ-9, C-SSRS) administered that day.

Administration

The administration block covers the dose, route, and the patient’s tolerance during administration. Dose (56 mg or 84 mg, with the device count), route (intranasal), administration time, and the patient’s response in the first 10 minutes (alert, oriented, comfortable, no acute adverse events). If you observe dissociation, sedation, or any vital sign change above the threshold in your protocol, that goes here.

Observation period

The 2-hour observation period is where most documentation defects appear. The note should show that the patient was observed for the full 2 hours by qualified personnel, with vitals and clinical status documented at the intervals your protocol specifies (typically 0, 40 min, 60 min, 90 min, and 120 min).

For each timepoint: blood pressure, heart rate, level of consciousness, presence or absence of dissociation, presence or absence of significant adverse effects. If the patient experienced a transient effect (mild dissociation, mild blood pressure elevation that resolved), document it and document the resolution. Charts that say “no adverse events” when one timepoint shows a BP of 162/98 are the ones that get bounced.

Discharge criteria

Before the patient leaves, the note should document that they meet your discharge criteria: vitals stable and within an acceptable range, fully alert, no acute adverse effects, ability to follow safety instructions about driving and operating machinery for the rest of the day, ride home arranged, and follow-up appointment scheduled.

If a patient does not meet discharge criteria at 2 hours, they stay. The chart should reflect the extended observation, the clinical reasoning, and the eventual discharge.

Assessment and plan

The assessment summarizes the patient’s response to today’s session and the trajectory across the protocol if this is not the first session. PHQ-9 trend across sessions belongs here. The plan covers the next session date, the dose for the next session, any adjustments to concomitant medications, and the safety plan in effect between now and the next visit.

Sample template structure

Patient: [name, DOB, MRN]
Session #: [n] of induction or maintenance phase
Date and time: [start to end]

Pre-session
- REMS attestation: prescriber, pharmacy, patient enrollment
- Indication: TRD, adequate antidepressant trials documented
- Current medications: [list]
- Baseline: BP, HR, PHQ-9, C-SSRS

Administration
- Dose: 56 mg / 84 mg (n devices)
- Route: intranasal
- Time of administration: [time]
- Initial response: [10-min check]

Observation
- T+0:    BP / HR / LOC / dissociation / AE
- T+40:   BP / HR / LOC / dissociation / AE
- T+60:   BP / HR / LOC / dissociation / AE
- T+90:   BP / HR / LOC / dissociation / AE
- T+120:  BP / HR / LOC / dissociation / AE

Discharge
- Vitals at discharge
- Mental status at discharge
- Discharge criteria met
- Ride home confirmed
- Next visit scheduled

Assessment
- Response to today's session
- PHQ-9 trend across sessions
- Tolerability

Plan
- Next session date and dose
- Concomitant medication
- Safety plan in effect

Where Nextvisit fits

Aria captures the conversational portions of the visit (pre-session check-in, post-administration discussion, discharge instructions) and routes them into the right sections. The vitals timepoints are entered as structured data from your existing tablet or paper form, and the system fills the table. The assessment writes itself from the captured conversation and the score trends, then you review and sign.

The full Spravato template is available at /templates. Most practices customize it lightly (vitals interval, protocol-specific add-ons) and have it running within an hour of import.