Agnikarma Procedure Note

Procedure Information

Procedure: [Agnikarma (thermal cautery) / electrocautery / chemical cautery / other thermal destruction modality] (Specify exact modality and instrument.)
Date/Time: [procedure date and time]
Location: [clinic / procedure room / other setting]
Operator: [name and credentials of clinician performing procedure]

Pre-Procedure Diagnosis

[Diagnosis or condition being treated]

Post-Procedure Diagnosis

[Diagnosis following procedure] (May be identical to pre-procedure diagnosis; must be explicitly stated.)

Indication and Target Site

[Clinical rationale for cautery]. Target: [anatomic location using standard terminology], [laterality: right / left / midline / bilateral], [number of sites or treatment points], [size measurements of treatment field if relevant]. (Laterality and site counts must be explicit; include mapping reference if used.)

Pre-Procedure Assessment

• Relevant risk factors: [bleeding risk, diabetes, neuropathy, immunosuppression, or other pertinent history] (State findings or "None identified.")
• Anticoagulant/antiplatelet status: [agent(s) and last dose / none / Not documented]
• Procedure-relevant allergies: [local anesthetics, antiseptics, topical agents with reaction type / NKDA / Not documented]
• Site assessment: [baseline skin integrity and any signs of infection] (Describe or "Not assessed.")

Informed Consent

Consent obtained from [patient / legal representative (relationship)], [written / verbal]. Discussion included: nature of procedure, expected benefits, material risks (pain, burn/blistering, infection, bleeding, scarring/pigment change, nerve injury, need for repeat treatment, poor response), and alternatives including no treatment. Questions answered; patient agreed to proceed. (If consent not obtained, document exception and rationale. Never leave blank or infer consent.)

Time-Out Verification

Time-out performed immediately prior to procedure with [team present / specific roles] and patient participation. Confirmed: correct patient identity, correct procedure, correct site and laterality, equipment available and functional. Site marking: [used / not required]. (If not performed, document rationale.)

Pain Control / Anesthesia

Pain control method: [none / topical anesthetic / local infiltration / regional block]. [If anesthetic used: agent, concentration, dose/volume, administration site]. Baseline pain score: [numeric score / Not obtained]. (If no anesthesia used, explicitly state "Pain control: none"; do not leave blank.)

Procedure Details

Patient positioned [position]. Skin prepared with [antiseptic agent / none]. Using [instrument/modality: heated probe/shalaka with material type / electrocautery tip / chemical cautery agent], [heating/energy method: thermal source / electrosurgical settings]. Application pattern: [point/spot / linear / field], [number] applications delivered with approximate spacing of [distance], [brief contact / contact duration if tracked]. Immediate tissue response: [blanching / expected tissue effect]. Hemostasis: [achieved / not required / method used]. Patient tolerance: [description]. Estimated blood loss: [volume / minimal / none]. Dressing: [type applied / none]; topical agents: [agent(s) / none]. (Document what is known; do not fabricate precision. Application counts and sites must remain explicit.)

Immediate Outcome

Patient [tolerated procedure well / other description] with [objective anchor: stable vitals / pain score change from X to Y / no distress / neurovascular status intact]. Immediate clinical response: [e.g., reduction in focal tenderness / not assessable at this time]. Condition: [awake, alert, stable for discharge / other].

Complications

[None observed] (This section must never be blank. If complications occurred, document: event, severity, actions taken, patient response, and follow-up plan.)

Aftercare Instructions

• Wound care: [dressing changes, hygiene, when site may get wet, topical agents to apply or avoid]
• Pain management: [recommendations and expected discomfort timeline]
• Activity restrictions: [restrictions relevant to treated site]
• Expected post-procedure effects: [localized tenderness, mild blistering, typical course]
• Return precautions: [fever, spreading redness, purulent drainage, uncontrolled pain, large blistering, numbness/weakness, bleeding not controlled with pressure]

Instructions provided [verbally / written / both]. Patient verbalized understanding.

Follow-Up

[Timeframe and clinic/provider for follow-up; guidance on when to return sooner if needed]

Attestation

[Provider signature and credentials]