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OpNote: Shoulder | Hip | Knee Joint Injection
ENTER OpNote Macro then "Injectate LOT/Exp" Macro here OR 'click' options below:
Shoulder Injection
PREOPERATIVE DIAGNOSIS
PREOPERATIVE DX
POSTOPERATIVE DIAGNOSIS
POSTOPERATIVE DX
PROCEDURE
PROCEDURE
MAC [Yes] / Local [No] (SPRING)
TIVA [Yes] / Local [No]
IV Sedation [Yes] / Local [No]
INDICATION
INDICATION
OPERATIVE PROCEDURE
Lying Prone with MAC Yes / No
Prep
Shoulder Location (Fluoroscopy)
Shoulder Location (Sitting)
Shoulder Location (Fluoroscopy) No Dye
COMMENTS
Hip Injection
PREOPERATIVE DIAGNOSIS
POSTOPERATIVE DIAGNOSIS
PROCEDURE
TIVA [Yes] / Local [No]
IV Sedation [Yes] / Local [No]
INDICATION
OPERATIVE PROCEDURE
Lying Supine with MAC Yes / No
Lying Lateral with MAC Yes / No
Prep
Hip Location (Fluoroscopy)
Hip Location (Without Fluoroscopy)
Knee Injection
PREOPERATIVE DIAGNOSIS
• • •
POSTOPERATIVE DIAGNOSIS
• • •
PROCEDURE
TIVA [Yes] / Local [No]
IV Sedation [Yes] / Local [No]
INDICATION
Procedure
Diagnosis
OPERATIVE PROCEDURE
With Sedation Yes / No
Patient Position Yes [Supine] / No [Sitting]
Supine Knee Position Yes [Flex] / No [Extend]
Prep
Approach (Without Fluoroscopy)
Approach (Fluoroscopy)
RECOVERY / DISCHARGE
Tolerated well? Yes / No
Tolerated Procedure Free Write
Recovery Room [Yes] / Direct Discharge [No]
Recovery Room Transport
Recovery / Discharge Free Write
Injectate Product Information
Fluoroscopy Image #1
Fluoroscopy Image #2
Fluoroscopy Image #3

360 SOAP Plan Medical Form

Pain Management Specialist

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Published: Jan. 22, 2022, 4:48 p.m.
Doctor: Dr. History Physical
Rating: +5   /

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