Panchakarma Treatment Plan (Course Protocol)

Patient Name: [Patient full name]

DOB: [Date of birth]

MRN/ID: [Medical record number or patient ID]

Contact: [Preferred contact information]

Emergency Contact: [Name; relationship; phone]

Course Start Date: [Start date]

Target End Date: [Target end date]

Planned Sessions & Cadence: [Total number of sessions and frequency]

Primary Reason for Course: [Primary indication]

Authoring Clinician: [Name, credentials]

Facility/Service: [Facility or service name]

Document Version: [Version number]

Date Created: [Creation date/time]

Last Updated: [Last updated date/time]

Course Overview & Assessment

Chief Concern and Goals

[Chief concern in patient's words] [Patient-stated goals] [Treatment goals including symptom targets, functional targets, and objective measures] (If goals are not yet finalized, state: "Goals pending—will finalize after baseline assessment.")

Indications

• [Ayurvedic assessment including dosha pattern and vikriti]
• [Conventional diagnoses or reported history] (Label whether each diagnosis is within practitioner scope or reported from outside sources.)

Assessment Synthesis

[Narrative synthesis of prakriti, vikriti/imbalance pattern, agni status, ama indicators, and relevant biomedical factors] [Clinical reasoning for selected course components, intensity, and duration] (Acknowledge uncertainty where evidence is limited.)

Planned Phases

• Preparatory (Purva karma): [Date range] — [Key interventions planned]
• Main Procedures (Pradhana karma): [Date range] — [Key interventions planned]
• Post-Procedure (Paschat karma): [Date range] — [Key interventions and recovery milestones]

Safety & Eligibility

(For safety-critical items, if information is missing, document as "Pending" with plan to complete. Do not omit.)

Risk Factor Screen

• Cardiopulmonary: [Pertinent history/status / Pending]
• Renal/Hepatic: [Pertinent history/status / Pending]
• Gastrointestinal: [Pertinent history/status / Pending]
• Pregnancy/Lactation: [Status / Pending]
• Bleeding Risk/Coagulopathy: [Pertinent history/status / Pending]
• Allergies/Sensitivities: [List of allergies to oils, botanicals, foods / None reported / Pending]
• Skin Integrity: [Pertinent findings / Pending]

Medications

• Prescription medications: [List with indications] (Flag anticoagulants, antihypertensives, diabetes medications.)
• OTC medications: [List / None]
• Supplements/Ayurvedic products: [List / None]

No changes to prescribed medications without coordination with prescribing clinician.

Contraindication Screen

(Include only procedure categories planned for this course.)

• Oleation: Screened: [Yes with date / Pending] — [Contraindications or precautions identified] — [Required modifications or enhanced monitoring]
• Sudation: Screened: [Yes with date / Pending] — [Contraindications or precautions identified] — [Required modifications or enhanced monitoring]
• Elimination procedures: Screened: [Yes with date / Pending] — [Contraindications or precautions identified] — [Required modifications or enhanced monitoring]
• Nasya: Screened: [Yes with date / Pending] — [Contraindications or precautions identified] — [Required modifications or enhanced monitoring]
• Other: [Procedure name] — Screened: [Yes with date / Pending] — [Contraindications/precautions] — [Modifications/monitoring]

Baseline Data

• Vitals: BP [value], HR [value], RR [value], Temp [value], Weight [value] (If not obtained, state "Pending" or "Not obtained.")
• Pertinent exam findings: [Findings / Pending]
• Labs/diagnostics reviewed: [Results with dates / Not available / Pending]

Eligibility

Disposition: [Eligible / Eligible with modifications / Not eligible / Deferred] — [Brief rationale]

• Conditions required before starting: [Requirements to meet eligibility or safety]
• Predefined stop/hold triggers: [Clinical thresholds or events requiring pause or discontinuation]

Informed Consent

[Consent discussion summary including nature and purpose of course, expected benefits, material risks, alternatives discussed, and evidence uncertainty] (For elimination procedures, specifically document discussion of dehydration and electrolyte risks.) [Patient questions and concerns addressed] [Patient decision] Written consent obtained: [Yes / No] — Stored: [Location]

Care Coordination

• Other clinicians involved: [Names, roles, contact / None]
• Clearance requests: [Requested from, date, outcome / None required]
• Communication plan: [How and when updates will be shared with other providers]

Course Protocol

Schedule

(List all planned sessions. Use day numbers if exact dates unknown.)

• Day [#] / [Date]:
  • Intervention(s): [Planned procedures]
  • Duration: [Expected duration]
  • Provider: [Name/role]
  • Pre-checks: [Fasting status, vitals, symptom screen, other requirements]
  • Monitoring level: [Standard / Enhanced]

(Repeat for each planned session.)

Intervention Parameters

(Include only procedure categories planned for this course. Keep entries brief; detailed procedural steps documented in separate session notes.)

• Oleation: [Clinical intent] — [Number and frequency of sessions] — [Oils/substances used] — [Key parameters: temperature, volume, application sites, duration]
• Sudation: [Clinical intent] — [Number and frequency of sessions] — [Method and substances] — [Key parameters: temperature, duration, target areas]
• Elimination procedures:
  • Vamana: [Intent] — [Sessions] — [Inducing agents] — [Adequacy criteria]
  • Virechana: [Intent] — [Sessions] — [Agents and doses] — [Adequacy criteria]
  • Basti: [Type: Anuvasana / Niruha / Other] — [Intent] — [Sessions] — [Formulation and volume] — [Retention time]
• Nasya: [Clinical intent] — [Number and frequency of sessions] — [Substances] — [Key parameters: dose per nostril, positioning, post-care]
• Other: [Procedure name] — [Intent] — [Sessions] — [Materials] — [Key parameters]

Monitoring

• Minimum each session: Pre/post vitals, symptom check, hydration tolerance assessment
• Enhanced monitoring triggers: [Clinical findings prompting increased monitoring frequency or intensity]
• Output tracking for elimination procedures: [Method/scale used] — [Person responsible] — [Documentation location]

Stop Criteria & Escalation

• Hold/stop criteria: Hypotension (SBP < [threshold] or symptomatic); syncope/presyncope; severe or worsening pain unrelieved by adjustments; bleeding; persistent vomiting beyond planned therapeutic range; signs of dehydration (tachycardia, orthostasis, low urine output); allergic reaction or substance intolerance; new neurologic deficit or acute concerning change
• Immediate actions: Stop procedure; assess vitals; position for safety; oral rehydration if tolerated; notify supervising clinician
• Escalation plan: [Criteria for EMS activation] — [Transfer destination] — [Emergency contacts]
• Adverse event documentation: [Required note elements] — [Incident report location] — [Timeline for completion]

Diet & Patient Instructions

• Preparatory phase: [Dietary guidance]
• Main procedures: [Dietary guidance]
• Post-procedure progression: [Stepwise reintroduction plan and duration]
• Hydration: [Targets and electrolyte considerations]
• Activity restrictions: [Restrictions and duration]
• Written instructions provided: [Yes / No] — Teach-back performed: [Yes / No]

Updates & Signatures

Reassessment Schedule

• Baseline: [Date] — [Assessment focus] — [Continue/modify/stop criteria]
• Pre–main procedure: [Date] — [Assessment focus] — [Criteria]
• Post–main procedure: [Date] — [Assessment focus] — [Criteria]
• End-of-course: [Date] — [Assessment focus] — [Criteria]
• Follow-up: [Date/timeframe] — [Assessment focus] — [Next steps]

Modification Log

(Maintain running log of all plan changes. If none, state: "No modifications to date.")

• [Date] — [Author] — [Change made] — [Rationale] — Patient notified: [Yes / No]

Signatures

Author: [Name, credentials] — [Signature] — [Date/time]

Supervising Clinician: [Name, credentials] — [Co-signature] — [Date/time] (If required by policy.)