Intrathecal Drug Delivery Pump Refill/Programming Procedure Note

Date/Time: [Date and time of procedure]
Location: [Clinic/facility and room]
Performing Clinician: [Name, credentials]
Pump Model: [Manufacturer and model] (Omit if unknown)
Reservoir Size: [mL] (Omit if unknown)
Therapy Indication: [chronic pain / spasticity / both]
Implant Date: [Date] (Only include if available from interrogation)
Battery/Service Life Status: [Status] (Only include if available from interrogation)

Pre-Procedure Assessment

Treated Condition: [Primary diagnosis/condition treated via intrathecal therapy, with laterality/region if relevant]
Today's Indication: [scheduled refill / dose adjustment for inadequate control / dose reduction for adverse effects / concentration change / medication change / troubleshooting]

Interval History Since Last Refill:
[Symptom trajectory and functional impact]
[Breakthrough symptom patterns]
[Adverse effects possibly related to intrathecal therapy: sedation, nausea, pruritus, urinary retention, weakness, cognitive changes, falls]
(If interval assessment was not performed, state: "Interval assessment not performed")

Red-Flag Screen:
Overdose/underdose/withdrawal symptoms: [present / absent]
Infection signs (pocket site/systemic): [present / absent]
New neurologic deficits: [present / absent]

Relevant Concurrent Medications: [CNS depressants, anticoagulants] (Only include if clinically relevant)
Relevant Allergies: [Antiseptics, local anesthetics, infusate components] (Only include if clinically relevant)

Consent

Risks, benefits, and alternatives were discussed; patient consented to proceed. Material risks discussed: [infection / bleeding / pocket fill / overdose / withdrawal]. (Do not document "patient understands" unless specifically verified.)

Time-Out

Time-out performed verifying correct patient, procedure [refill / refill with programming], pump pocket site, and medication(s)/concentration(s) to be instilled.

Pre-Refill Pump Status

Pre-Refill Settings:
Expected Reservoir Volume: [mL]
Alarm Status: [Low reservoir alarm date/time; active alerts]
Battery Status: [Status]
Current Drug(s) and Concentration(s): [List each drug with concentration in consistent units]
Current Delivery Parameters: [Continuous/basal rate] | [Total daily dose] | [Flex dosing schedule] | [Programmed boluses] | [Patient-controlled dosing: dose, lockout, max doses/day, enabled/disabled] (Include applicable parameters only)
Programmer Report: [saved/scanned]
(If interrogation could not be performed, state why and identify alternative information source used.)

Procedure

Patient Position: [Position]
Pump Pocket Location: [e.g., LLQ abdomen]
Skin Assessment Over Pump: [Infection / erosion / seroma / hematoma: present / absent] (If present, describe findings)
Aseptic Technique: [Skin prep agent(s) and sterile technique used]
Local Anesthetic: [Agent and volume] (Omit if none used)
Access Technique: [Noncoring needle type/size] | Refill template: [used / not used]

Volume Reconciliation (Mandatory—complete prior to signing)
Actual Volume Withdrawn: [mL] | Appearance: [clear / other]
Expected Volume: [mL] (from interrogation)
Discrepancy: [mL] (Actual − Expected)
[If discrepancy exceeds local/device threshold or shows upward trend, document interpretation and response]

Medication Instilled (Mandatory)
Drug: [Generic name; note preservative-free if applicable]
Concentration: [mg/mL or mcg/mL]
Total Volume Instilled: [mL]
[For multi-drug admixture, list each component with concentration]
Source: [commercial / compounded pharmacy] (Include when relevant)
[If concentration changed or decreased: Reservoir rinse performed per manufacturer protocol: [yes / no]]

Immediate Tolerance/Complications: [Pain at site / bleeding / hematoma / vasovagal symptoms / none]
Pocket Fill Concern: [absent / present] (If present, describe actions taken)

Post-Refill Settings and Programming

Programming Changes: [No programming changes made today / Programming changes made] (State explicitly)

[If programming changes made: Clinical rationale—symptom-driven (inadequate control, adverse effects) and/or safety-driven (extend refill interval, respond to discrepancy trend). For substantial dose changes, include percent change from prior total daily dose and brief risk/benefit statement.]

Post-Refill Settings:
Drug(s) and Concentration(s): [List]
Reservoir Volume Entered: [mL]
Continuous/Basal Rate: [Units/time]
Total Daily Dose: [mg/day or mcg/day]
[Flex dosing schedule] (Include if applicable)
[Bolus settings with limits/lockouts] (Include if applicable)
Low Reservoir Alarm: [Date/time]
Pump Update: [successful / unsuccessful—explain]

Bridge/Priming Bolus

(Include this subsection only if a bridge or priming bolus was programmed; otherwise omit entirely)
Indication: [concentration change / catheter transition / other]
Key Inputs: Catheter volume: [mL] | Prior concentration: [units] | New concentration: [units]
Programmed Bolus Parameters: [Dose, rate, duration]
Monitoring Plan: [Location, duration, parameters monitored]

Post-Procedure Assessment

Post-Procedure Vitals: [Vitals] (Include if obtained)
Immediate Response: [Symptom change / side effects / neurologic status / respiratory status]
Observation Period: [Duration]
Disposition: [discharged home / extended observation / transfer]
[If high-risk programming (bridge bolus, large dose increase, restart after interruption): Document enhanced monitoring pathway and confirm overdose/withdrawal precautions reviewed with patient]

Plan

Next Refill Date: [Absolute date, e.g., March 10, 2026] (Mandatory)
Low Reservoir Alarm: [Date/time as programmed] — Instruct patient to schedule appointment before alarm date
Follow-up After Dosing Change: [Phone check timing / clinic follow-up timing] (Include if dose changed)
Pump Replacement Planning: [Notes] (Include if near end-of-service)
Patient/Caregiver Education: Written refill schedule and emergency contact information provided: [yes / no]

Procedure Summary

Post-Procedure Diagnosis: [Condition]
Procedures Performed: [interrogation / refill / reprogramming / bridge bolus]
Complications: [none / specify]
Key Quantitative Summary: Actual [mL] vs Expected [mL] (Discrepancy: [mL]) | [Drug, concentration, volume instilled] | New total daily dose: [dose] (if changed)
Attachments: [Programmer printout saved/scanned]

(Do not infer absence of adverse effects, sterility, patient tolerance, pocket fill status, or programming changes unless explicitly stated. Volume reconciliation, drug/concentration, volume instilled, and next refill date are mandatory fields. Use consistent units throughout.)