Panchakarma Therapy Session Note

Patient Name: [Patient full name]

DOB: [Date of birth]

Date of Service: [Service date]

Session Time: [Start time] to [End time]

Session Number: [Session number within planned series]

Setting/Location: [Clinic room / spa suite / home visit / other]

Practitioner: [Practitioner name and credentials]

Referring Plan/Order: [Reference to prescribing practitioner and treatment plan / Patient-requested wellness service]

Indication & Session Goals

[Primary indication and functional goal for today's session] (1–3 sentences. Reference intake or treatment plan for detailed history rather than repeating. If wellness-only with no acute complaints, state explicitly.)

Pre-Session Status & Safety Screen

• Consent & Privacy: [Identity verification method]; [Consent status for listed procedures]; [Draping method]; [Areas to avoid and rationale if any]
• Contraindication Screening: [General red flags assessed: acute illness, fever, infection, syncope risk, dehydration]; [Procedure-specific screens as relevant: heat intolerance, oil/powder allergies, airway sensitivity, scalp/eye concerns]; [Screening status: completed / not assessed with reason] (Do not default to "denies all"; document what was actually asked and answered.)
• Patient-Reported Status: [Sleep, stress, pain/tension, fatigue since last session]; [Response to prior session: improved / unchanged / worsened / delayed reaction]; [Last meal and hydration if relevant to heat tolerance]
• Vitals: [BP]; [HR]; [Temp]; [SpO2] (Include when indicated by heat/steam use, cardiopulmonary risk, syncope risk, or per protocol. If not obtained, document: "Vitals not obtained—low-risk manual session, patient asymptomatic" or state reason.)
• Focused Observations: [Skin integrity]; [Edema]; [Gait steadiness]; [Alertness]; [Other pertinent findings]

Procedures Performed

(Document each distinct procedure performed today. Repeat the block below for each procedure.)

[Procedure name in standardized terminology]

• Body Regions: [Regions treated]
• Positioning: [supine / prone / lateral / seated / other]
• Timing: Start [HH:MM]; Stop [HH:MM]; Duration [minutes]
• Therapist(s): [Names and roles]
• Materials: [Medicament type: oil / powder / decoction / other]; [Product name and base]; [Key botanicals or essential oils if used]; [Quantity]; [Lot/batch/expiry if clinic-compounded or allergy risk elevated]
• Preparation & Temperature: [Preparation method]; [Temperature verification method]; [Target temperature if monitored]
• Equipment: [Steam generator / dhara stand / droni / covers / eye pads / ear protection / other as applicable]
• Technique Parameters: [Pressure: light / moderate / firm]; [Stroke direction if clinically meaningful]; [Steam parameters: source, medicaments, distance, exposure time]; [Shirodhara parameters: flow type, oscillation pattern, stream height]; [Temperature maintenance method] (Include only parameters relevant to procedure performed.)
• Intra-Procedure Monitoring: [Comfort checks and patient responses]; [Modifications requested and actions taken]; [Pauses or early stops with reason]; [Intra-session vitals if indicated]; [Safety measures: slip/burn precautions, eye/ear protection]
• Completion Status: [completed as planned / modified / stopped early]—[If modified or stopped, describe change and rationale]

Patient Response & Tolerance

[Overall tolerance summary] (1–2 sentences: tolerated well, mild discomfort, requested modification, session stopped early, etc.)

• Patient-Reported: [Relaxation, sleepiness, symptom relief]; [Any discomfort: headache, nausea, dizziness, itch, rash, eye irritation]
• Clinician-Observed: [Skin changes: erythema, rash]; [Sweating level]; [Gait steadiness]; [Alertness]
• Pre/Post Measures: [Pain scale, stress rating, or other measures if used]
• Adverse Events: [No adverse events observed or reported] OR [Event description, onset time, severity, actions taken, outcome, escalation/referral]

Post-Session Instructions

• Immediate Aftercare: [Hydration, rest, shower timing, oil management]
• Behavioral Precautions: [Avoid cold/wind exposure, intense exercise, alcohol for specified period]
• Diet Guidance: [Light foods, timing relative to next session if applicable]
• Safety Red Flags: [Rash, eye pain, persistent dizziness, shortness of breath, severe headache, burns—when to seek care]
• Follow-Up: [Next appointment date/time]; [Planned adjustments for next session]
• Teach-Back: [Performed for key safety points: yes / no] (If instructions not given or patient departed early, document why and how instructions were communicated.)

Assessment & Plan

[Clinical impression of today's response relative to session goals]; [Updated risk considerations if any] (1–3 sentences. May be brief or omitted for routine wellness sessions if Response section adequately captures outcomes.)

Plan: [Continue / adjust] [procedure(s)]; [Specific changes planned and rationale]; [Follow-up timing]; [Referrals or escalation if indicated]

Signature

Practitioner Signature: [Signature]

Credentials: [Credentials]

Date/Time Signed: [Date and time]