KAP Dosing Day Documentation Toolkit

Document medicine sessions with greater clarity, confidence, and clinical consistency.
 
The KAP Dosing-Day Progress Note Toolkit is a practical documentation resource for therapists who provide ketamine-assisted psychotherapy and want a clearer way to capture the clinical work, safety considerations, client response, and care coordination involved on medicine days.
 
Dosing-day notes can feel especially complex. Therapists may need to document psychotherapy interventions while clearly distinguishing their role from the prescriber’s role, tracking safety and risk, recording relevant vital signs or medical information appropriately, and reflecting the realities of in-person, virtual, group, or couples-based care.
 
This toolkit gives you a structured, adaptable foundation for documenting the full medicine-session arc, without relying on vague language or copying a generic psychotherapy note.
 
Inside this toolkit, you’ll receive:
A comprehensive KAP dosing-day progress note template
Documentation language for safety, risk assessment, and escalation planning
Scope-of-practice and prescriber-collaboration language
Vitals and monitoring documentation guidance
In-person individual dosing-session example
Virtual/sublingual dosing-session example
Group dosing-session example
Couples session example in which one partner receives medicine and the other participates as a support person
Guidance for documenting client response, therapist interventions, and post-session disposition
Audit-readiness checklist
Common documentation mistakes and stronger alternatives
 
This resource is designed for therapists who want their documentation to reflect the actual skill involved in holding KAP medicine sessions: presence, attunement, risk awareness, ethical boundaries, and meaningful clinical judgment.
 
Best for: KAP therapists, therapists collaborating with ketamine prescribers, clinicians offering in-person or virtual KAP support, group KAP facilitators, and couples KAP therapists.
 
Format: Digital download

Please note: This resource is educational and should be adapted to your license, state requirements, payer rules, practice policies, and collaborative-care model.