Dermal Filler Injection Procedure Note

Patient name: [Patient full name]    DOB: [MM/DD/YYYY]    MRN: [Medical record number]

Date of procedure: [MM/DD/YYYY]    Time: [HH:MM]    Clinic/facility location: [Facility name and address]

Injector: [Name, credentials]    Assistant(s): [None / Name(s) and role(s)] (Only include if applicable)

Procedure Identification

Procedure: Dermal filler injection.
Anatomic areas treated: [Areas with laterality].
Indication: [cosmetic / reconstructive / medical].
Regulatory status: [on-label / off-label / site not FDA-approved]. (Document explicitly when off-label or non-FDA-approved site)

Same-day procedures: [None / neuromodulator / other procedure].
This note documents: [filler only / combined visit]. (Clarify if other procedures performed)

Pre-Procedure Assessment

(Include only information explicitly documented in the encounter)

• Relevant history: [Prior fillers/implants, dates if known; prior complications or outcomes; pertinent medical/dermatologic history].
• Contraindication screening: Active infection at treatment sites [Yes / No]; Bleeding risk or anticoagulant use [Yes: specify / No]; Pregnancy or breastfeeding [Yes / No / Not applicable].
• Allergies: [Allergy list, specifically addressing lidocaine and antiseptic agents].
• Focused examination: Baseline asymmetry [Present: describe / Absent]; Scars [Present: describe / Absent]; Skin integrity [Intact / Compromised: describe]; Vascular concerns in treatment zones [None / Describe].
• Procedural plan: [Areas and product class planned; goals]. Anatomic marking: [Performed / Not performed].

Informed Consent

Discussion and understanding: Patient had opportunity for questions and expressed understanding of risks, benefits, and alternatives including no treatment.

• Standard risks reviewed: Bruising, swelling, pain, lumps/irregularity, infection, delayed nodules/granulomas, asymmetry, need for touch-up, allergy.
• Facial vascular risk: Vascular occlusion including potential skin necrosis; where anatomically relevant, vision changes/blindness and stroke discussed.
• HA filler reversibility: [Discussed / Not applicable]. (Document if HA products used)
• Site-specific or off-label counseling: [Not applicable / Specific risks discussed and patient acceptance documented].

Consent status: Written consent signed and stored at [REQUIRED: consent storage location].

Safety Verification

• Patient identity verified (two identifiers): [Yes / No: explain].
• Procedure and sites confirmed: [Yes / No: explain].
• Allergies reviewed: [Yes / No: explain].
• Product verification: Correct product, intact packaging, not expired [Confirmed / Not confirmed: explain].
• Markings match planned sites: [Yes / Not applicable / Corrected prior to procedure].
• Time-out: [Performed / Not performed: reason].

Products and Devices

Product (manufacturer/brand/name)	Material type	Syringe size	Syringes opened	UDI or Lot number	Expiration date	Contains lidocaine
[Product name]	[HA / CaHA / PLLA / PMMA / other]	[mL]	[#]	[REQUIRED: UDI or Lot]	[MM/YYYY]	[Y / N]
[Product name]	[Material type]	[mL]	[#]	[REQUIRED: UDI or Lot]	[MM/YYYY]	[Y / N]

(Add or remove rows to match products used)

Total filler volume used: [REQUIRED: total mL]    Waste/discard: [mL / None].

Anesthesia:

• Topical: [None / Agent and concentration] applied for [duration] minutes.
• Local infiltration/nerve block: [None / Agent, concentration, volume, sites].
• Note: [No anesthesia used / No additional anesthesia; product contains lidocaine / Additional anesthesia as above].

Skin prep and asepsis: [Antiseptic agent] applied; aseptic technique maintained.

Procedure Details

Patient position: [supine / seated / semi-recumbent / other].

Area/Side	Product	Injection plane	Device	Technique	Volume (mL)	Comments
[Anatomic area, L/R/bilateral]	[Product name]	[intradermal / deep dermal / subcutaneous / supraperiosteal]	[needle / cannula], [gauge]G, [length] mm	[bolus / linear threading / fanning / depot / cross-hatching]	[mL]	[Entry points, molding, notable anatomy]
[Anatomic area, L/R/bilateral]	[Product name]	[Injection plane]	[Device details]	[Technique]	[mL]	[Comments]

(Add rows for each distinct area/side and technique)

Total volume injected: [REQUIRED: total mL]. Reconciliation: [Matches syringes opened / Discrepancy: explain].

Immediate Outcome and Complications

Tolerance and result: [Patient tolerance description]. Immediate aesthetic outcome [satisfactory / needs further staging / other].

Vascular compromise assessment: [No concerning pain, blanching, livedo/reticular discoloration, or visual symptoms during or immediately after injection / Findings: describe signs, area(s), timing, actions taken, and response].

Complications: [None / Describe].

(If adverse event occurred, document timestamped entries below)

• [Time]: [Signs/symptoms]. Actions: [Interventions performed]. Response: [Patient status]. Follow-up arranged: [Specific plan].

Post-Procedure Instructions

Aftercare provided: Standard post-filler instructions reviewed; [handout name] provided. Written and verbal instructions given; patient verbalized understanding.

Red-flag symptoms reviewed (seek urgent evaluation if present):

• Unusual, severe, or worsening pain
• Vision changes, new headache, or neurologic symptoms
• Skin color change (pale/white/gray/blue), mottling, or coolness
• Fever, spreading redness, or severe swelling

After-hours contact: [Clinic contact instructions]. Emergency instructions: [Instructions for vision changes or severe symptoms].

Disposition: [Stable at discharge]. [Accompanied by: relationship / Unaccompanied]. (Include accompaniment only if relevant)

Follow-Up

Planned follow-up: [Timeframe] [in person / telehealth].
Photography: [Baseline and follow-up photos planned / Not planned].
Staged treatment plan: [None / Next areas, products, and timing].

(If required data—product UDI/lot, total volumes, consent documentation, or vascular assessment—are not available from dictation, retain placeholders labeled "REQUIRED" rather than omitting. Remove unused table rows and inapplicable options.)