Foot/Ankle Injection Procedure Note

Date/Time: [Date and time of procedure]

Location: [Facility/clinic/procedure room]

Performing Clinician: [Name, credentials]

Indication

[Working diagnosis, laterality, and specific target structure] (Include 1–2 sentences noting prior conservative treatment or clinical rationale for injection. If conservative history is unknown, use neutral language such as "persistent symptoms despite conservative measures.")

Allergies and Safety Screen

(Include this section only if a focused safety screen was performed; omit entirely otherwise.)

• Allergies reviewed: [local anesthetics / corticosteroids / prep agents: pertinent positives and negatives]
• Safety considerations: [skin condition at site / anticoagulation status / diabetes / other] (Include only if applicable.)

Informed Consent

[Verbal / written] consent obtained per policy. Risks, benefits, and alternatives discussed; patient questions answered; patient agreed to proceed. (Include target-specific risks when relevant, such as fascia rupture or fat pad atrophy for plantar fascia injections, or tendon weakening for tendon sheath injections.)

Pre-Procedure Verification

Correct patient, procedure, site, and laterality verified prior to starting. [Allergies confirmed.] (Include allergy confirmation only if performed.)

Procedure Details

(Repeat this entire section for each distinct injection site. Each site requires its own laterality, target, and medication volumes.)

Procedure Performed: [Injection name with laterality]

Anatomic Site: [Target structure and approach]

Patient Position: [Positioning and landmarks used]

Skin Preparation: [Prep agent] using [aseptic / sterile] technique

Guidance: [Landmark-guided / ultrasound-guided / fluoroscopy-guided] (Never infer guidance method. If ultrasound-guided: include real-time needle visualization and target confirmation; images saved: [yes / no]. If landmark-guided: briefly describe anatomic landmarks used.)

Needle: [Gauge and length] (Omit if not provided.)

Technique: [Entry site and trajectory]. Aspiration performed: [yes / no]. (If fluid aspirated: [appearance, volume, disposition: discarded / sent for analysis].)

Medications Administered:

• [Medication name, concentration]: [volume mL] ([dose mg] if corticosteroid)
• [Medication name, concentration]: [volume mL] ([dose mg] if corticosteroid)
• Total injectate: [total volume mL]

Dressing: [Pressure/hemostasis/bandage applied]

Tolerance and Complications

Patient [tolerated the procedure well / tolerance description]. [No immediate complications. / Complication(s) and management.] (Always document complications or their absence.)

Post-Procedure Instructions

Patient counseled on: [expected course including transient numbness, delayed steroid onset, possible post-injection flare]; [activity guidance]; [wound care if applicable]; [red flags for infection or worsening symptoms]; [glucose monitoring for diabetic patients if steroid administered]. Follow-up: [timeframe and plan].

Medication Wastage

(Include only when billing for drugs from single-dose containers or when required by local workflow; omit entirely otherwise.)

[Drug name and concentration]: [total in vial mL]; administered [volume mL]; discarded [volume mL]. (If no waste: "No medication waste.")

Disposition and Follow-Up

[Patient disposition]. [Follow-up plan and next steps if symptoms do not improve].

(Required elements: laterality and specific target structure, guidance method, informed consent, medications with name/concentration/volume/mg dose for corticosteroids, and complications statement. Never infer laterality, injection site, medication doses, or guidance method.)