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PROCEDURE NOTE:
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Diagnosis _1
• • •
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Comments on Diagnosis
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Informed consent
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Ultrasound Evaluation
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Body Region
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Limited or Complete
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Indication
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Provider
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Type of Cleansing Agent _4
• • •
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Needle size? _5
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CC's of Lidocaine used? _6
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CC of steroid used _7
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Type of Steroid _8
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Total volume injected _9
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Location of Injections _10
• • •
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Comments on injection location
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After care
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Lot Number
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New Free Draw
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New Free Draw
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New Free Draw
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