Biologic Infusion Procedure Note

Patient: [Patient name], MRN: [MRN], DOB: [DOB] | Date of Service: [YYYY-MM-DD] | Location: [Site/facility name] | Ordering Clinician: [Name, credentials] | Infusion Nurse: [Name, credentials] | Visit Type: [Scheduled / Add-on / Urgent] | Dose in Series: [Dose number and phase, e.g., "Dose 3 of induction" or "Maintenance dose 5" / Not applicable]

(Use 24-hour time format throughout. Omit patient identifiers if EHR auto-stamps them.)

Indication

[Primary diagnosis] — [Biologic therapy name (generic); include biosimilar name if applicable]. [Regimen phase: induction / maintenance], [Interval, e.g., q8 weeks]. [Reference to ordering plan or protocol]. [Recent dose or interval changes and rationale, if any]

(Brief, medical-necessity oriented statement. Do not infer details not present in the record.)

Pre-Infusion Verification

(If any item is not completed, document reason, who was notified, go/no-go decision, and mitigation taken.)

• Two patient identifiers verified: [Yes / No] — [Method per policy]
• Allergy review completed: [Yes / No] — [Allergens and reaction types / None reported]
• Prior infusion reaction history reviewed: [Yes / No] — [Agent, date, severity / None known]
• Medication reconciliation completed; interactions/contraindications considered: [Yes / No] — [Notable findings / None]
• Order verified (drug, dose, route, diluent, planned rate/duration): [Yes / No] — [Details]
• Weight-based dosing: [Yes / No / N/A] — Current weight: [Weight in kg] (Time: [HH:MM]) | Dosing weight if different: [Weight in kg] | Calculated dose verified: [Yes / No]
• Contraindication screening completed: [Yes / No]
  • Fever/infection symptoms: [Present / Absent] — [Details if present]
  • Pregnancy status (if applicable to agent): [Negative / Positive / Unknown / N/A] — [Verification method/date]
  • Required labs current: [Yes / No] — [Lab names and dates] (If abnormal but proceeding, document clinician awareness and rationale.)

Pre-Infusion Assessment

• Baseline symptoms relevant to indication: [Summary for trend comparison]
• Focused reaction-risk assessment: Respiratory: [Findings] | Skin: [Findings] | Cardiovascular: [Findings]
• Baseline vitals: Time [HH:MM] — BP: [BP], HR: [HR], RR: [RR], Temp: [Temp], SpO₂: [SpO₂], Weight: [Weight if dose is weight-based]
• Pertinent labs: [Required labs and most recent dates]. Acceptable to proceed: [Yes / No]. [If abnormal but proceeding, document clinician notified and rationale]

Vascular Access

Access Type: [Peripheral IV / PICC / Port / Tunneled catheter] | Site: [Location and laterality] | Gauge: [Gauge if peripheral] | Patency: [Confirmation method] | Dressing/Site Condition: [Description] | Attempts: [Number and complications if applicable]

(If infiltration/extravasation suspected, document expanded details in Complications section.)

Premedications

[Medication name] — [Dose], [Route], [Time HH:MM] — Indication: [Indication] — Response: [Response]

(List each premedication on separate line. If none given, state "Premeds: None administered.")

Biologic Infusion

• Infused Product: [Biologic generic name; biosimilar name if applicable] — Dose ordered: [Dose] — Dose administered: [Dose] (If variance: [Reason]) — Concentration: [Concentration] — Total volume: [Volume] — Diluent: [Type/volume if applicable] — Route: IV — Delivery method: [Infusion pump / Gravity]
• Timing: Start [HH:MM]; Stop [HH:MM] (Record both absolute times; do not record only total duration.)
• Rate: Initial rate: [Rate]. Titration per protocol: [Yes / No]. [Staged rates and times if applicable]
• Interruptions: [None] or Paused: Stop [HH:MM], Restart [HH:MM], Reason: [Reason], Rate adjusted: [Yes / No — new rate if yes]
• Product Identifiers: Lot #: [Lot number]; NDC: [NDC] (Include especially if reaction occurs.)
• Dose Accounting: Total supplied: [Amount] — Administered: [Amount] — Discarded: [Amount and disposal method / No drug discarded] (Required for JW/JZ modifier billing.)

Monitoring During Infusion

• Monitoring schedule: [Vitals per protocol: baseline, frequency during infusion, end of infusion, post-observation period] (If reduced monitoring per policy for short infusions, state rationale.)
• Vitals during infusion:
  • Time [HH:MM] — BP: [BP], HR: [HR], RR: [RR], Temp: [Temp], SpO₂: [SpO₂], Pain: [Pain score if relevant]

(Add rows for each time point obtained.)

• Tolerance narrative: [1–3 sentences documenting presence or absence of infusion reaction symptoms: rash/urticaria, pruritus, flushing, throat tightness, dyspnea/wheeze, chest discomfort, hypotension, nausea/vomiting] (Only document "none observed" if actually assessed.)

Complications

[No adverse events or complications during infusion]

(If complication occurred, document below. Omit subsections that do not apply.)

• Infusion reaction:
  • Onset time: [HH:MM / Exact onset time unknown]
  • Signs/symptoms: [Objective and patient-reported findings]
  • Severity: [Mild / Moderate / Severe per local policy]
  • Immediate actions: [Infusion stopped/paused, oxygen, positioning] — Provider notified: [Name, time] — Orders received: [Actions]
  • Medications for reaction: [Drug, dose, route, time, response]
  • Vital signs around event: [Time-stamped vitals]
  • Restarted: [Yes / No] — Restart time: [HH:MM] — Restart rate: [Rate] — Tolerance after restart: [Findings]
  • Disposition: [Completed / Discontinued] — [Observation / ED transfer / Admission / Discharge]
  • Patient counseling: [Delayed/biphasic reactions and return precautions discussed]
• Infiltration/extravasation:
  • Site description: [Location, appearance, symptoms]
  • Estimated volume infiltrated: [Volume]
  • Steps taken: [Actions per protocol]
  • Notifications: [Provider/pharmacy notified, times]
  • Follow-up plan: [Reassessment, imaging, clinic follow-up]

Post-Infusion and Discharge

• Completion status: [Completed as ordered / Partially administered — explanation]
• Line management: [Flush performed], [Access removed / Locked per protocol], Site condition: [Description]
• Post-infusion vitals: Time [HH:MM] — BP: [BP], HR: [HR], RR: [RR], Temp: [Temp], SpO₂: [SpO₂]
• Condition at discharge: [Ambulatory status, pain/distress level, mentation if sedating premeds used]
• Discharge destination: [Home / Returned to unit / ED / Admitted]
• Instructions provided: [Verbal and/or written instructions provided; patient verbalized understanding]. After-hours contact: [Provided / Not provided — reason]

Follow-Up

• Next infusion: [Interval]; due [Date range] — Scheduling: [Clinic will schedule / Patient to schedule] — Contact: [Method]
• Prerequisites: [Required labs with due date, screening updates, authorizations if applicable]
• Provider appointment: [Date / To be scheduled / Not applicable]

Authentication

Author: [Name], [Credentials], [Role] — Signature: [YYYY-MM-DD HH:MM]

(Corrections should be documented as addenda with date/time and reason.)