KAP Session Checklist

Patient's First Name *

Patient's Last Name *

Patient's Email *

Patient's Phone *

Did the patient show up for the Patient Preparation Appointment

Yes

No

Introduction & Confirmation of Details

Reference: Planning Ahead Checklist

Introduce yourself and explain the purpose of the call.

Obtain the patient's consent to proceed with the pre-check.

Medication, Equipment, Supplies.

Patient Meds should have arrived via Miller's Pharmacy, a Daywel Company.

Confirm the client’s medication(s) have arrived.

Confirm the patient’s welcome kit with blood pressure monitor has arrived.

Creating Your Setting & Setting Intentions

References: Creating Your Space

References: Music Selections

Inform the patient to spend some time thinking about their intentions and goals for the upcoming session.

Ensure a comfortable, safe, and supportive environment.

Minimize potential distractions and create a peaceful atmosphere.

Discuss the selected music playlist and ask patient to test their equipment for music playback before their session.

Review the Adult Chaperone and their Role

Reference: Coming Soon to Website

Chaperone's First Name

Chaperone's Last Name

Chaperone's Phone Number

Chaperone's Email

Confirm the contact information for the adult supervisor if available.

Assist in Checking Vitals-

Reference- Blood Pressure Protocols

Verify that the patient has a functional blood pressure monitor and knows how to use it.

Inform the patient that they will want to check and record their blood pressure before beginning the session and again 2-3 hours after the session.

Record Patients current Blood Pressure by having them test their monitor.

Enter patient's diastolic blood pressure

Enter patient's systolic blood pressure

Select a blood pressure range

Normal: Less than 120/80 mmHg
Elevated: Systolic between 120-129 mmHg and diastolic less than 80 mmHg
Stage 1 hypertension: Systolic between 130-139 mmHg or diastolic between 80-89 mmHg
Stage 2 hypertension: Systolic at least 140 mmHg or diastolic at least 90 mmHg
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Ketamine, Side Effects and Dosage Preparation

Reference: Ketamine Use Consent

Review the potential effects, risks, and benefits of the specific psychedelic substance.

Review the recommended dosage guidelines for their session.

Discuss strategies for navigating challenging experiences and remind the patient of the support available.

Remind the patient to stay hydrated but to avoid eating and any excess fluids for a minimum of 3-4 hours prior to session.

Food & Nutrition, Wrap Up

Remind patient to follow this checklist online: Session Preparation

Answer any remaining questions or concerns the patient may have.

Remind the patient to get a good night's sleep and approach the session with an open and curious mindset.

Additional Notes

Enter any additonal notes about the preparation session

Thank you for completing we will follow up with the patient for the next steps.