IV Therapy Charting & Protocol Note (ND)

Administration

Patient Name: [Patient Name]

Date of Infusion:

Practitioner Name:

Administered by (RN / ND / other):

Allergies (medications, preservatives/sulfites, latex):

Current Medications / Supplements:

Relevant Medical History (cardiac, renal, hepatic):

Pre-Infusion Assessment

Protocol & Indication

Protocol name:

Protocol kind:

Nutrient

Heavy-metal chelation

Hydration

Other: ________

Indication / diagnosis:

Protocol

Protocol Kind

Nutrient Infusion

Protocol Name

e.g. Myer's Cocktail

Completion Status

Planned

Heavy Chelation Protocol

Final Volume (mL)

e.g. 250

Container

e.g. Bag, Bottle

Administration

Administration timestamp

YYYY-MM-DD HH:MM

Administration person

Search staff member...

Administration role

Select role...

CTCAE Events (Adverse Events)

Adverse Events List Add event

No adverse events recorded.

Consent & Safety Screen

Indication discussed & informed consent obtained:

Risks/benefits/alternatives explained:

Contraindication screen (G6PD status if high-dose vitamin C, renal/cardiac/fluid-overload risk, pregnancy, drug interactions):

G6PD status (if applicable):

Normal

Deficient

Not tested

Precautions noted:

Pregnancy status:

Yes (weeks: _______)

Pre-Infusion Vitals

Blood Pressure

Systolic · mmHg

Diastolic · mmHg

Heart rate · bpm

Anthropometrics

Weight · kg

KG LB

Height · cm

CM FT/IN

Temperature · °C

°C °F

Notes

Infusion Detail

Composition

Ingredient	Dose	Volume (mL)	Route	Lot # / Expiration	Notes (rate, time)

Container / base solution:

Final total volume (mL):

Access & Administration

IV access – site:

IV access – gauge:

IV access – attempts:

Infusion rate:

Start time:

Completion time:

Total volume infused (mL):

Completion status:

Completed

Partial

Aborted (reason: _______)

Post-Infusion

Post-infusion vitals:

BP: _______ / _______ mmHg

HR: _______ bpm

Temp: _______ °C

SpO2: _______ %

Patient tolerance:

Adverse events (none / describe):

Adverse event severity (CTCAE grade 1–5):

Action taken:

Discharge instructions provided:

Warning signs reviewed (fever, site redness/swelling, dyspnea, chest pain, rash, delayed reaction):

Plan & Follow-Up

Monitoring parameters (labs, symptom review, response markers):

Next treatment / follow-up interval:

Escalation / referral criteria:

ND - IV Therapy Charting and Protocols

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