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PROCEDURE NOTE
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Date
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NAME OF PROCEDURE
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Injection of which side?
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Other
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Injection of what body part?
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Other
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Injectate
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Guidance
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LOGISTICS
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Pre-Procedure Diagnosis:
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Post-Procedure Diagnosis:
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Physician:
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Describe any complications?
• • •
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Other
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Indication
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SAMPLE PREP
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How much blood drawn?
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More specific?
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What kit?
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PRP Return (CCs)?
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Saved PPP?
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LOCAL ANESTHESIA
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Patient Position
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Palpation Guided?
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Anatomic-Guidance (describe)
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Cleaning Agent
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Wheal of local placed?
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Anesthetize deeper tissues?
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In/Out of Plane?
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Direction
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Other Direction
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Structure Visualized
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Axis
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Anest # Gauge Needle
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Local Anesthesia Injectate
• • •
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CCs for local
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INJECTATE
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Injectate Needle
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US Guided?
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Injection in/out of plane
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Injection target
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LAX SAX
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CCs injectate
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List Injectate (all components)
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Easy?
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Explain:
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POST-INJECTION
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Did ok?
• • •
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Band-aid??
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Explain
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% relief
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Pre-Proc VAS
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Post-Proc VAS:
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PLAN
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New Multiple Select
• • •
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