Nasya Procedure Note

Date/Time of Procedure: [Date and time of procedure]

Location: [Facility/clinic room]

Clinician: [Name and credentials]

Procedure: Nasya

Indication

[Clinical indication and therapeutic goal] (Briefly state the reason for Nasya and intended outcome. Include 1–2 relevant clinical context points that justify the intervention such as presenting symptoms or prior treatment response. Include a contraindication screening statement such as "No contraindications identified per clinic protocol" or document pertinent findings if present. If the indication is unclear at time of documentation, explicitly state this rather than inferring.)

Consent

[Consent details] (Document who provided consent—patient or authorized representative—whether written or verbal consent was obtained, and confirm discussion of procedure, expected benefits, risks including irritation, epistaxis, and coughing/choking sensation, alternatives including no treatment, and opportunity for questions. Affirm that the patient agreed to proceed. Do not infer consent from procedure performance.)

Pre-Procedure Verification

[Time-out performed per clinic policy / Time-out not required per clinic protocol] (If performed, briefly confirm correct patient, procedure, substance, and laterality. This section may be omitted if time-out is not required per facility policy.)

Substance Administered

Substance: [Name and formulation] (Specify type—oil, ghee, decoction, etc.)

Temperature: [ambient / warmed / cooled / not applicable]

Dose: [Drops per nostril and total] [bilateral / right nostril / left nostril] (Required; do not leave blank.)

Route: Intranasal

Source: [clinic-supplied / patient-supplied] (Include lot/batch number and expiration date if tracked; otherwise state "not recorded per clinic workflow.")

Allergy check: [Confirmed no known allergies or sensitivities / Allergy or sensitivity identified—specify and document mitigation] (Required; confirm status relative to the administered substance.)

Technique

• [Patient positioning] (Describe body and head position.)
• [Administration method] (Specify dropper, syringe, or pledget.)
• [Sequence and laterality] (Order of administration; include breathing instructions or guidance to avoid swallowing if provided.)
• [Dwell/rest period] (Duration of rest after instillation and position maintained.)
• [Deviations from standard approach] (Note any modifications such as partial dosing or comfort-related adjustments. Omit if none.)

Patient Response

[Tolerance and immediate response] (Use specific descriptors such as transient burning, coughing, tearing, or nasal irritation. Include patient-reported symptoms and observed responses. Include vital signs if measured.)

Complications: [No immediate complications / Complication occurred—describe type, severity, timing, actions taken, and outcome] (Always document explicitly, even if none.)

Post-Procedure Care

[Immediate care provided] (Document any measures performed such as rest period, gargle, or gentle nasal care.)

• [Restrictions and avoidances communicated] (List only instructions actually given.)
• Written instructions provided: [yes / no]
• [Patient understanding confirmed]
• Return precautions: [Symptoms that should prompt urgent contact]

Follow-Up & Disposition

Follow-up: [Next session timing or recommended interval; planned adjustments based on response]

Disposition: [Condition on departure] (e.g., stable, ambulatory) [Discharge destination]

Electronic Signature: [Clinician name and credentials]

Date/Time Signed: [Date and time of signature]

(If any safety-critical information was unavailable at the time of initial documentation, add a timely addendum rather than leaving fields blank.)