Carpal Tunnel Injection Procedure Note

Procedure: Carpal Tunnel Injection

Date: [Date]

Laterality: [Right / Left / Bilateral] (Required; must not be inferred)

Location: [Procedure location]

Proceduralist: [Name, credentials]

Indication

[Indication narrative stating suspected or confirmed carpal tunnel syndrome with relevant symptoms, diagnostic or therapeutic intent, and prior conservative measures if known] (Frame expected benefit as short-term symptom relief. Keep concise if comprehensive evaluation note exists from same encounter.)

Pre-Procedure Assessment

• Allergies reviewed: [Local anesthetics, corticosteroids, latex, skin prep agents, other, or NKDA]
• Relevant conditions/counseling: [Anticoagulation status and bruising risk counseling, diabetes status and transient hyperglycemia counseling, or none applicable]
• Skin at injection site: [Description confirming intact skin and absence of cellulitis or open wound] (Document each side separately if bilateral)
• Baseline neurovascular status: [Sensation to light touch in median distribution, thenar motor function if assessed, perfusion/capillary refill] (Document each side separately if bilateral. If any element not assessed, state "not assessed" rather than omitting.)

Informed Consent

Consent obtained: [Written / Verbal]. Discussion included indication, expected short-term symptom relief, alternatives (continued conservative care, surgical referral, observation), and material risks (infection, bleeding/bruising, nerve injury or symptom worsening, skin depigmentation, fat atrophy, steroid flare, allergic reaction, and transient hyperglycemia if diabetic). Patient verbalized understanding and agreed to proceed.

Time-Out

Immediately prior to needle insertion, correct patient identity, procedure, site, and laterality were verified, and allergies were reviewed.

Technique

[Aseptic technique with skin prep agent: alcohol / chlorhexidine / povidone-iodine]. [Approach: landmark-guided / ultrasound-guided]. [Anatomic entry description, e.g., volar wrist approach]. [Needle gauge and length if documented]. [Aspiration performed and result if applicable]. Laterality: [Right / Left / Bilateral]. (For bilateral procedures, document technique separately for each side.)

• Medications injected: [Medication name, concentration, dose in mg, volume in mL for each medication used]
• Total injectate volume: [Total mL]
• Difficulties: [Multiple attempts, blood return, paresthesia during injection, or none]
• Drug waste: [Amount discarded, drug name/concentration] (Include only if billing for discarded drug; document per CMS JW/JZ modifier requirements)

Ultrasound Guidance

(Include this section only if ultrasound was used; otherwise omit entirely)

• Clinical indication for ultrasound: [Reason for image guidance]
• Transducer: [Linear / other]
• Structures visualized: [Median nerve, carpal tunnel, adjacent structures]
• Images: Permanent images saved to medical record

Outcome

Patient tolerance: [Tolerated well / describe vasovagal or other symptoms]

Immediate complications: [None / describe complications] (Must be explicitly stated; do not infer)

Estimated blood loss: [Minimal / quantify if significant]

Post-Procedure Assessment

[Post-procedure sensation, perfusion/capillary refill, and any unexpected deficit] (Document each side separately if bilateral. Note expected transient numbness from local anesthetic versus unexpected deficit. Do not infer intact status; document what was assessed.)

Post-Procedure Instructions and Follow-Up

• Dressing: [Dressing applied]
• Activity: [Guidance provided, e.g., avoid heavy wrist use for 24–48 hours]
• Expected course: [Local anesthetic duration, possible steroid flare for 24–48 hours]
• Red flags reviewed: Increasing redness/warmth/swelling, fever, drainage, persistent or worsening numbness/weakness beyond expected anesthetic window, severe pain
• Condition-specific counseling: [Diabetes: monitor glucose more frequently for 24–72 hours / other / none]
• Follow-up: [Timeframe and provider]