Documenting a Spravato session step-by-step

A Spravato visit takes two hours: REMS attestations, vitals at multiple points, and a 2-hour observation period. Payers audit these claims more often than almost any other psychiatric service. Documentation defects are the usual denial.

A working template is in the library at /templates.

Pre-session

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

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. It should also appear in the note text so it is searchable on audit.

Indication: treatment-resistant depression with adequate trial documentation, or major depressive disorder with acute suicidal ideation per the FDA label. Reference the clinical assessment that supports the indication. Do not only state it.

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

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

Administration

Dose, route, and 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 a vital-sign change above your protocol threshold, that goes here.

Observation period

The 2-hour observation period is where most documentation defects appear. The note should show the patient was observed for the full 2 hours by qualified personnel, with vitals and clinical status 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 there was 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, document that they meet discharge criteria: vitals stable and in an acceptable range, fully alert, no acute adverse effects, able to follow safety instructions about driving and operating machinery for the rest of the day, ride home arranged, follow-up scheduled.

If they do not meet criteria at 2 hours, they stay. Chart the extended observation, the reasoning, and the eventual discharge.

Assessment and plan

The assessment summarizes today’s response 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 next dose, any adjustments to concomitant medications, and the safety plan in effect until 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 (pre-session check-in, post-administration discussion, discharge instructions) and routes them into the right sections. Vitals timepoints come in as structured data from your tablet or paper form, and the system fills the table. The assessment drafts from the captured conversation and score trends. You review and sign.

The full Spravato template is at /templates. Customize it for your vitals interval and protocol-specific add-ons.