Intralesional Injection Procedure Note (Corticosteroid)

Date/Time of Procedure: [Date and time of procedure]

Location: [Clinic/facility and room]

Clinician: [Clinician name and credentials]

Patient Name: [Patient full name]

DOB/MRN: [Second patient identifier per local policy]

Intralesional Injection Procedure Note (Corticosteroid)

Intralesional [corticosteroid drug - REQUIRED] [concentration mg/mL - REQUIRED] injected: total [total volume mL - REQUIRED] ([total dose mg - REQUIRED]) into [number of lesions - REQUIRED] lesion(s) at [anatomic sites with laterality - REQUIRED]. (Do not infer any required element. If unavailable, flag as "REQUIRED - MISSING.")

Indication and Target Lesions

[Clinical indication: diagnosis and rationale for injection, such as symptoms, inflammation, or failed prior therapy] (1–2 sentences.)

• [Lesion type] — [explicit count - REQUIRED], [anatomic location with laterality - REQUIRED] (Optional: [lesion size] / [photo reference])
• (Add additional lines per distinct lesion type or site as needed.)

Pre-Procedure

• Allergies: [Relevant allergies to corticosteroids, local anesthetics, antiseptics] (State "None" if no relevant allergies.)
• Pertinent risk factors: [Clinically relevant factors for this procedure, e.g., active infection at site, anticoagulation, diabetes if larger dose] (Omit if none.)

Informed Consent

[Verbal / written] consent obtained from [patient / legal representative with relationship - REQUIRED] after discussion of benefits, risks, and alternatives; questions answered; patient agreed to proceed. [Form location if written consent.] (Consent status is required. If not obtained, document reason and that procedure was not performed.)

Risks reviewed:

• Pain/discomfort
• Bleeding/bruising
• Infection
• Skin atrophy/indentation
• Pigmentary change (hypo- or hyperpigmentation)
• Telangiectasia
• Ulceration
• [Location-specific risks if applicable, e.g., periocular vision-related concerns]
• [Systemic steroid effects if larger doses used]

Verification

Correct patient, procedure, and site(s) confirmed prior to start. [Formal time-out performed / Time-out not required per local policy].

Medication Administered

(All REQUIRED fields must be completed. Do not infer concentration, volume, or dose.)

• Corticosteroid

  • Medication: [Generic name - REQUIRED]
  • Concentration: [mg/mL - REQUIRED]
  • Total Volume Injected: [mL - REQUIRED]
  • Total Dose: [mg - REQUIRED]
  • Route: Intralesional
  • Dilution: [Diluent and final concentration] (Include only if diluted.)
  • Needle: [Gauge and length] (Optional.)

• Local Anesthetic (Include only if used.)

  • Medication: [Generic name]
  • Concentration: [Percentage or mg/mL]
  • Volume: [mL]
  • Route: [Infiltrative / topical]

Procedure Technique

[Antiseptic used] applied; aseptic technique employed. Anesthesia: [none / topical agent / local infiltrative with agent, concentration, and volume]. Injection performed intralesionally into [target lesion(s)] using [plain-language technique description]. [Technique endpoints if used, e.g., mild blanching].

Sites and Volume Distribution

• [Site/lesion description] — [volume mL]
• [Site/lesion description] — [volume mL]

(If per-site volumes were not tracked: Total [volume mL] distributed across [number] lesions at [listed sites].)

Outcome and Tolerance

Procedure [completed as intended / aborted or incomplete with reason]. Patient [tolerated well / tolerated with difficulty]. Hemostasis [achieved / not required]. Dressing: [Applied / none]. Specimens: None.

Complications

[No immediate complications / Description of complication, management provided, and patient status at end of visit] (REQUIRED — do not leave blank.)

Post-Procedure Instructions

Aftercare instructions provided. Local wound care discussed; expected transient effects (mild swelling, soreness) reviewed. Red flags for return reviewed: increasing pain, spreading redness, drainage, fever, skin depression, pigment changes [, visual symptoms if periocular]. [Written instructions provided / verbal instructions only].

Follow-Up

[Follow-up timing and modality]. Return sooner if [criteria for earlier return]. [Plan for repeat injection if applicable, stated as criteria-based rather than definitive]. [Response tracking method if used: photo, symptom score, measurement].