Intrathecal Baclofen Pump Refill/Reprogramming Procedure Note

Note title: Intrathecal Baclofen Pump Refill/Reprogramming Procedure Note | Date/Time: [Start time] – [End time] | Care setting: [Clinic / Hospital bedside / OR / Other] | Performing clinician & role: [Name, credentials] | Reason for encounter: [scheduled refill / low-reservoir alarm / dose adjustment / symptom evaluation / post-MRI check / other] | Encounter type: [refill and programming / refill only / programming only / interrogation only]

Indication and Clinical Context

[Underlying etiology of spasticity] (If etiology is not confirmed in records, explicitly state that it is uncertain or not documented.)

• Targeted problems: [spasticity / spasms / positioning / pain / hygiene / transfers / sleep / caregiver burden]
• Therapy intent and goals: [comfort vs function goals, relevant trade-offs such as maintaining extensor tone for transfers]

Interval History and Safety Screening

Chief concern: [Patient/caregiver stated reason for today's visit]

Interval changes: [Changes since last visit including spasticity status, functional impact, and any triggers such as infection, constipation, medication changes, or hospitalization]

Structured safety screening: (Document both positives and pertinent negatives. For routine visits with no concerns, a compact summary such as "Safety screening completed; all items negative" is acceptable.)

• Overdose/toxicity symptoms: [sleepiness / dizziness / hypotonia / respiratory symptoms / confusion / seizures / none reported]
• Underdose/withdrawal symptoms: [return of spasticity / pruritus / paresthesias / fever / altered mental status / rigidity / none reported] (Flag severe warning signs if present.)
• Pump/system concerns: [alarms / unexpected symptom swings / headaches / pump site pain / none reported]
• Infection concerns: [fever / pocket redness / drainage / warmth / tenderness / none reported]
• MRI since last visit: [yes / no] (If yes, document whether post-MRI interrogation was performed.)

Objective Examination

Vitals: [Vital signs] (Include mental status and respiratory assessment if overdose concern.)

• General/mental status: [alertness, orientation, respiration, distress]
• Neurological/musculoskeletal: [tone distribution, clonus, spasms, functional observations] (If standardized scales used, specify scale name, score, and body region.)
• Pump pocket/site: [skin integrity, erythema, swelling, tenderness, warmth, drainage]

(If exam not performed, state explicitly with reason.)

Pre-Procedure Device Interrogation

(Include this section whenever refill or programming is performed.)

• Pump identification: [Model] | [Reservoir size in mL] | [Implant date] | [Location/side]
• Battery status: [Normal / ERI / EOS]
• Pre-procedure reservoir volume (per programmer): [mL]
• Low reservoir alarm date / Expected empty date: [Date]
• Current drug: Intrathecal baclofen | Concentration: [mcg/mL]
• Current dosing program: [continuous / flex / scheduled bolus] | Total daily dose: [mcg/day]
• Flex schedule: [Time segments and rates] (Include only if flex dosing.)

(If interrogation fails, document what could not be obtained, troubleshooting attempted, and safety plan.)

Refill Procedure

(Include this section only when refill is performed. Omit entirely if no refill occurred.)

Consent and verification: [Procedure explained, risks reviewed, consent obtained; patient identity confirmed, correct procedure/site verified, medication confirmed]

Sterile technique: [Skin prep agent] | [Sterile barriers used] | [Needle type/gauge] | [Number of access attempts] (Document if more than one attempt.)

Port identification: [Reservoir fill port confirmed] | [Identification method: palpation with template / other] (This must be explicitly documented at every refill.)

Volume reconciliation:

• Expected volume (from programmer): [mL]
• Actual volume aspirated: [mL]
• Discrepancy: [Actual – Expected = X mL] | [within tolerance / concerning]
• Interpretation/Actions: [Assessment of discrepancy and any actions taken if concerning]

Medication instilled:

• Drug: Intrathecal baclofen | Concentration: [mcg/mL] | Volume instilled: [mL]
• Lot #: [lot] | Expiration: [date] (If unavailable, document why and mitigation steps.)
• Waste/disposal: [amount and method] (Include only if applicable.)

Concentration change protocol: (Include only if concentration changed.)

• Reservoir rinse: [yes / no] | [number of rinses]
• Bridge bolus programmed: [yes / no] | [parameters and rationale]

Immediate post-refill status: [Patient tolerance and any complications including bleeding, hematoma, pain, vasovagal symptoms, or concern for pocket fill/wrong-port access]

Reprogramming

(Include this section only when programming changes are made. If settings were reviewed but unchanged, state "Programming reviewed; no changes made" and omit the table below.)

Programming changes:

• Total daily dose (mcg/day): Prior [value] → New [value]
• Mode: Prior [continuous / flex / bolus] → New [continuous / flex / bolus]
• Flex schedule segments: Prior [list] → New [list] (Include only if applicable.)
• Concentration: Prior [mcg/mL] → New [mcg/mL] (Include only if changed.)
• Low reservoir alarm date: Prior [date] → New [date]

Rationale for changes: [Clinical trigger, expected benefit, balance of tone reduction vs functional needs, magnitude justification, and reassessment plan]

Post-Procedure Monitoring

• Observation: [duration and location] (If abbreviated for stable patient, document rationale and that return precautions were given.)
• Post-procedure vitals/neuro status: [values/observations if obtained]
• Adverse symptoms/events: [none / details and interventions]

Patient and Caregiver Education

(This counseling is mandatory and must be explicitly documented as completed.)

• Refill schedule reviewed: [yes / no] | Next refill target date: [date] | [Instructions if appointment cannot be kept]
• Emergency contacts reviewed: [yes / no] (Clinic number and after-hours pathway)
• Overdose recognition and actions reviewed: [yes / no] (Drowsiness, weakness, respiratory symptoms, confusion)
• Withdrawal recognition and actions reviewed: [yes / no] (Return of severe spasticity, itching; warning signs: fever, altered mental status, rigidity)
• When to seek ED vs call clinic urgently reviewed: [yes / no]
• MRI safety reviewed: [yes / no] (Need for post-MRI pump interrogation)
• Written instructions provided: [after-visit summary / handout / none]

Assessment and Plan

1. Spasticity due to [etiology]: [Current status]; Goals: [comfort / function]; ITB settings: [mode, total daily dose, concentration]; Adjunct therapies: [PT / OT / oral medications / orthoses / other]
2. ITB pump management: [Refill completed / not performed]; Volume discrepancy: [within tolerance / concerning with actions]; Battery status: [status and replacement planning if approaching ERI/EOS]
3. Safety/education: Overdose/withdrawal counseling completed: [yes / no]; Alarms and refill schedule documented: [yes / no]

Follow-Up

• Next refill appointment: [date or scheduling window]
• Interim check after dose change: [phone check / in-person visit / none] | [timeframe] (Include only if dose was changed.)
• Return precautions: Seek emergency care for severe sedation, respiratory distress, rapidly escalating spasticity with systemic symptoms, fever with pump pocket concerns, pump alarm with symptoms, or new neurologic decline.