Facet Joint Injection/Medial Branch Block Procedure Note

Patient: [Patient full name], [DOB], [MRN]. Date/Time: [Procedure date] [Start time – End time]. Location: [Facility name and setting]. Proceduralist: [Name, credentials]. Procedure Performed: [Diagnostic / Therapeutic] [intra-articular facet joint injection / medial branch block] at [specified spinal level(s)] [cervical / thoracic / lumbar], [left / right / bilateral]. Diagnosis: [Clinical diagnosis]. Indication: [One-line clinical indication noting failure of conservative measures; for diagnostic blocks include potential candidacy for radiofrequency ablation if positive response].

Indications and Medical Necessity

[Summary of predominantly axial pain location, severity, and duration] [Functional impact with named assessment score if available (e.g., ODI) or brief functional narrative] [Prior conservative management and response (PT, medications, activity modification)] [Relevant prior facet procedures and response]. (If specific conservative management details are not available at the time of the procedure, reference the most recent clinic evaluation note by date and author rather than leaving blank.)

Baseline Assessment

• Pain score (NRS 0–10): [Pre-procedure NRS score] ([laterality if unilateral]).
• Baseline function: [Brief statement of key limitations in ADLs/ROM/ambulation/occupation].
• Provocative tasks to reassess: [Task 1], [Task 2], [Task 3]. (For diagnostic blocks, list 1–3 tasks such as extension, rotation, facet loading, or sit-to-stand. Omit for therapeutic injections if not applicable.)

Pre-Procedure Verification

• Allergies reviewed: [Medication / latex / prep agent / contrast allergies or none reported].
• Anticoagulant/antiplatelet status: [Agent(s) and peri-procedure plan / none / not documented].
• Infection screening: [No fever, no local skin infection / findings].
• Pregnancy status: [Negative / not applicable]. (Include if applicable.)
• Sedation plan: [None / agent, dose, route]. (For diagnostic blocks, sedation should be avoided or minimized. If sedation beyond local anesthetic is used, include medical necessity justification.)
• Informed consent: Obtained after discussion of risks including bleeding, infection, allergic reaction, vasovagal event, transient increased pain, nerve injury, and radiation exposure.
• Time-out: Completed verifying patient identity, correct procedure, correct site/side/level(s), allergies, and team agreement.

Procedure Details

[Patient position] on the procedure table. Skin prepped with [prep agent] and draped in sterile fashion. Local anesthesia to skin and subcutaneous tissues with [agent, concentration, volume]. Imaging guidance with [fluoroscopy / CT] using [views used] for localization and needle placement.

Per-Target Documentation

• Target: [Facet joint (IA) / Medial branch nerve] at [level], [left / right].

  • Needle: [Gauge, length].
  • Placement confirmation: [Bony contact / fluoroscopic landmarks / CT position] with [views]; contrast [used / not used]. (If contrast not used, document reason and confirmation method.)
  • Injectate: [Medication name(s), concentration(s), volume per target]. (MBB typically ≤0.5 mL per nerve; IA facet typically <1.5 mL per joint.)
  • Complications at target: [None / blood or CSF aspiration / paresthesia / intravascular uptake / aborted].

(Repeat per-target entry for each joint or nerve. If multiple targets share a syringe, document total syringe contents and allocated volume per target.)

Completion: Needles removed intact. Hemostasis achieved. Sterile dressing applied. Patient tolerated the procedure [well / with difficulty].

Immediate Post-Procedure Assessment

• Pain score (NRS 0–10): [Post-procedure NRS] at [time from procedure, e.g., 15 minutes]. (Must use same scale as baseline.)
• Percent relief of index pain: [Patient-reported % relief].
• Functional reassessment: [Task 1: improved / same / worse]; [Task 2: improved / same / worse]; [Task 3: improved / same / worse]. (Reassess the same tasks listed at baseline.)
• Neurologic status: [Intact / findings]. (Include for cervical/thoracic procedures or if clinically indicated.)

(For diagnostic blocks, note whether immediate response aligns with expected anesthetic onset. Longer-interval assessment via pain diary is required before determining diagnostic outcome.)

Complications

[No complications / Description of event: vasovagal episode, allergic reaction, new neurologic symptoms, intravascular uptake, dural puncture, bleeding/hematoma]. (This field must not be omitted—explicitly state presence or absence of complications.)

Plan

• Observation and discharge: Observed until [stable vital signs / ambulation / other criteria]. Discharge criteria met.
• Activity restrictions: [Restrictions and duration].
• Anticoagulant resumption: [Timing and instructions]. (Include if applicable.)
• Glucose monitoring: [Instructions and contact threshold]. (Include if corticosteroid administered to diabetic patient.)
• Pain diary: [Time-stamped pain score instructions during expected anesthetic window]. (Include for diagnostic blocks.)
• Return precautions: Reviewed: fever, severe headache, progressive weakness or numbness, bowel/bladder dysfunction, injection-site drainage or swelling, uncontrolled pain.
• Follow-up: [Appointment timing]. [Next steps based on response].