Raktamokshana Procedure Note (Bloodletting/Leech Therapy)

Date: [Date] Start/End Time: [Start time – End time]

Location/Setting: [Clinic / Procedure room / Inpatient unit / OR / Other]

Performing Clinician: [Name, credentials]

Patient Name: [Full name]

DOB: [DOB] MRN: [MRN]

Session: [Session __ of __ / Single session]

Procedure Site: [Anatomic site and laterality: Right / Left / Bilateral / Midline]

Procedure Summary

Raktamokshana via [Jalaukavacharana (leech therapy) / Siravedha (venesection) / Pracchana (scarification/cupping)] to [target site with laterality] for [indication]; [tolerated well / complications noted / estimated amount removed: __ mL]. (Limit to a single concise line.)

Pre-Procedure Diagnosis and Indication

Diagnosis: [Primary diagnosis or working diagnosis] (If working diagnosis, state the clinical basis.)

Clinical findings: [Relevant symptoms, exam findings, or flap/venous congestion status prompting procedure]

Reason for procedure today: [Failure of conservative measures / Planned series / Change in status / Other]

Rationale for selected method: [Brief explanation] (If using Ayurvedic assessment elements, phrase in clinically interpretable terms.)

Contraindications and Risk Review

• Anticoagulant/antiplatelet use: [Yes / No / Unknown] (If Yes: [agent, dose, last dose time])
• Bleeding history/coagulopathy: [Yes / No / Unknown] (If Yes: [details])
• Anemia risk/baseline Hgb: [Low risk / Elevated risk / Unknown]; Hgb [__ g/dL / not available]
• Immunosuppression/infection risk: [Yes / No] (If Yes: [cause/medications])
• Site skin integrity: [Intact / Erythema / Ulceration / Infection / Other]
• Relevant allergies: [Antiseptics / Dressings / Local anesthetics / Leeches / Antibiotics / None known]
• For flap/venous congestion—arterial inflow assessed: [Yes / No / NA] (If Yes: [clinical / Doppler])

Informed Consent

Consent provided by: [Patient / Parent / Guardian / Surrogate] Interpreter used: [Yes / No]

Risks discussed: Bleeding and prolonged oozing; anemia/possible transfusion; infection (include Aeromonas risk if leeches used); pain; vasovagal episode/syncope; allergic reaction; scarring or pigmentation changes; potential need for escalation.

Benefits discussed: [Symptom relief / Reduced congestion / Other therapeutic goal]

Alternatives offered: [No procedure / Medical management / Other method(s)]

Consent documentation: [Signed consent form in chart / Verbal consent per policy with witness]

Pre-Procedure Verification and Time-Out

Time-out performed: [Yes / No / Not required per policy] (If No or Not required, provide explanation.)

• Patient identity verified: [Yes]
• Procedure, site, and laterality confirmed: [Yes]
• Allergies reviewed: [Yes]
• Equipment/materials available: [Yes]
• Site marking: [Performed / Not applicable]

Preparation

• Patient position: [Supine / Prone / Lateral / Sitting / Other]
• Skin preparation: [Chlorhexidine / Povidone-iodine / Alcohol / Not recorded]
• PPE/barrier precautions: [Sterile gloves / Clean gloves / Gown / Mask / Eye protection]
• Field setup: [Sterile drape / Clean field]
• Method-specific equipment: [Number of leeches / Needle gauge and collection method / Scarification instrument and cup type] (Include only items relevant to selected method.)

Anesthesia and Analgesia

[None used / Topical anesthetic: agent, site / Local infiltration: drug, concentration, volume, site / Sedation: see anesthesia record] (This section must not be omitted; if no anesthesia used, explicitly state "None.")

Procedure Details

Method: [Jalaukavacharana / Siravedha / Pracchana]

Anatomic site(s) and laterality: [Precise description with landmarks]

[Stepwise narrative of the procedure sufficient to reproduce the technique]

Jalaukavacharana (Leech Therapy)

(Include only if leech therapy performed.)

• Indication type: [Venous congestion/flap salvage / Inflammatory condition / Other]
• Leeches applied/attached: [__ applied / __ attached]
• Application sites: [Anatomic description]
• Duration: [Time until detachment or removal method if not spontaneous]
• Estimated blood removed: [__ mL measured / __ mL estimated / qualitative description]
• Expected post-detachment oozing: [Duration/extent]
• Antibiotic prophylaxis: [Agent, dose, time / Not given: rationale]
• Leech disposition: [Biohazard disposal per protocol]

Siravedha (Venesection)

(Include only if venesection performed.)

• Vein accessed: [Anatomic site]
• Needle/cannula: [__G]; Attempts: [__]
• Volume removed: [__ mL] (Method: [graduated container / scale])
• Hemostasis: [Direct pressure __ min]; Dressing: [Type]
• Specimen handling: [Discarded per biohazard / Sent for testing]

Pracchana / Cupping-Based Bloodletting

(Include only if scarification/cupping performed.)

• Incisions/punctures: [Number and extent]
• Suction device: [Manual / Vacuum]; Cup type: [Glass / Silicone / Other]
• Area treated: [__ cm²]
• Approximate blood loss: [__ mL measured / __ mL estimated / qualitative description]
• Wound dressing: [Type applied]

Hemostasis: [Direct pressure / Topical hemostatic / Suturing]; Achieved: [Yes / No]

Total blood loss: [__ mL measured / __ mL estimated / Unable to quantify: reason]

Monitoring and Patient Response

• Baseline vitals: HR [__] BP [__] RR [__] SpO₂ [__]
• Interval vitals: [As recorded]
• Flap/congestion assessment: [Color / Capillary refill / Doppler findings] (If applicable.)
• Post-procedure status: Mental status [alert/oriented]; Pain [__/10]; Bleeding [controlled / expected oozing]; Dressing [clean/dry/intact]
• Patient response: [Subjective symptom changes]; [Objective findings: reduced congestion, improved color, decreased swelling]
• Tolerance: [Tolerated well / Mild discomfort / Other] (Support with observation such as stable vitals or absence of distress.)

Complications

[None observed] (If complications occurred, document below. Distinguish expected effects such as prolonged post-leech oozing from true complications.)

• Complication: [Description]
• Action taken: [Pressure dressing / Topical hemostatic / Suturing / Fluids / Antibiotics / Antihistamines]
• Response: [Clinical response and stability]
• Escalation: [Consult service and time / Transfer of care] (If applicable.)

Post-Procedure Care and Follow-Up

• Wound care: [Dressing type, change frequency, expected oozing duration, bathing restrictions]
• Medications: [Antibiotics / Analgesics / Topical agents with dose, route, duration]
• Activity restrictions: [Specify]
• Return precautions: Bleeding not controlled with pressure; dizziness/syncope; fever; expanding redness/swelling; purulent drainage; severe pain; allergic symptoms
• Follow-up: [Clinic follow-up timeframe]; [Next session plan if serial therapy]
• Disposition: [Home / Observation / Continued inpatient monitoring]; Escort [required / not required] (For inpatients: care plan per inpatient orders.)

Electronic Signature: [Clinician name, credentials, date/time]