Lip Augmentation Procedure Note (Injectable Filler)

Patient: [Patient name]

DOB: [Date of birth]

MRN: [Medical record number]

Date of Service: [Date]

Procedure Start Time: [Time]

Location: [Clinic/procedure room]

Provider: [Provider name, credentials]

Allergies: [Confirmed allergies; note any to filler components, lidocaine, antiseptics, or latex] (If none, state "No known drug allergies.")

Procedure Summary

[Concise overview: product type and brand; regions treated; total volume injected; anesthesia method; complications or "none"; disposition] (Limit to 3–5 sentences. If complications, total volume, or anesthesia not available, state "not documented.")

Indication and Goals

[Patient's stated goals and aesthetic priorities; include brief direct quote if clarifying] (Note if corrective or touch-up visit.)

• Prior filler history: [Product(s), treatment areas, timing, response, complications/dissolution]
• Bleeding risk factors: [Anticoagulants / antiplatelets / bleeding disorder / none]
• Relevant allergies: [Filler components, lidocaine, chlorhexidine, povidone-iodine, latex, or none]
• HSV history: [positive / negative / unknown]; Prophylaxis: [given with agent/dose/timing / not indicated / declined]
• Active infection/inflammation near injection site: [yes / no]
• Pregnancy/breastfeeding status: [status / not applicable]

Baseline Assessment

[Pre-injection exam: lip proportions, vermilion show, border definition, Cupid's bow and philtral columns, perioral lines/skin quality]

Palpation: [Nodules / firmness / tenderness / none]

Baseline asymmetry: [Describe any pre-existing laterality differences by location] (Required. If none present, state "No significant baseline asymmetry noted.")

Pre-Procedure Verification and Consent

• [Correct patient confirmed; planned regions reviewed with patient; allergies verified]
• [Product(s) selected and checked: correct product, packaging intact, lot verified, not expired]
• [Informed consent obtained covering: expected outcomes and variability; common effects (swelling, bruising, tenderness, early lumps); less common risks (infection, nodules, migration, inflammatory reactions); rare serious risks (vascular occlusion with potential skin necrosis, vision changes, neurologic symptoms, severe allergic reaction); and alternatives]
• Off-label use disclosed: [yes / no / not applicable]
• Consent status: [written, signed and filed / verbal consent obtained] (If verbal, document reason.)

Photography

Pre-procedure photographs obtained: [yes / no]

Views: [frontal at rest, obliques, smile, profile, close-up, other] (If photographs declined or not taken, document reason.)

Procedure Details

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

Skin/mucosal prep: [Agent and method]

Anesthesia: [Topical anesthetic with agent and application time / regional block with agent and volume / ice / none]; Filler contains lidocaine: [yes / no]

Product Traceability (Duplicate for each product used.)

Product: [Brand and variant]

Type: [HA with lidocaine / HA without lidocaine / other]

Lot #: [Lot number]

Expiration: [MM/YYYY]

UDI: [UDI code / not available]

Syringes Opened: [Number]

Total Volume Injected: [mL]

Volume Discarded: [mL / none]

Delivery device: [Needle or cannula with gauge and length]

Technique: [linear threading / serial puncture / fanning / depot / combination]; [retrograde / anterograde]; [plane(s) of injection]

Anatomic Mapping (Include only subunits treated; volumes should sum to total injected.)

• Upper vermilion border: [R / L / bilateral], [superficial / deep], [volume mL]
• Cupid's bow: midline, [superficial / deep], [volume mL]
• Philtral columns: [R / L / bilateral], [superficial / deep], [volume mL]
• Upper vermilion body: [R / L / bilateral], [superficial / deep], [volume mL]
• Lower vermilion border: [R / L / bilateral], [superficial / deep], [volume mL]
• Lower vermilion body: [R / L / bilateral], [superficial / deep], [volume mL]
• Oral commissures: [R / L / bilateral], [superficial / deep], [volume mL]
• Perioral rhytids: [R / L / bilateral], [superficial / deep], [volume mL]

Immediate Endpoint and Assessment

[Result achieved: symmetry, contour, border definition] [Tissue response: normal coloration, capillary refill, absence of blanching or disproportionate pain] [Patient feedback; mirror check performed: yes / no] [Molding/massage performed: yes / no]

Complications

[Complications observed: type, timing of onset, anatomic distribution, severity, interventions, and disposition] (If none, state "No complications observed.")

(For suspected vascular compromise: document time of recognition, time interventions started, specific signs observed, treatments administered, and escalation actions.)

Aftercare and Return Precautions

[Aftercare instructions provided: activity restrictions, heat/exercise/alcohol avoidance duration, makeup/skincare restrictions, ice application guidance, avoidance of manipulation]

Urgent return precautions reviewed with patient:

• Severe or worsening pain out of proportion to expected discomfort
• Skin blanching, mottling, dusky discoloration, blistering, or ulceration
• Fever, increasing warmth, or purulent drainage
• Visual symptoms (blurred vision, vision loss, eye pain)
• Neurologic symptoms (weakness, speech difficulty)
• Signs of severe allergic reaction (wheezing, facial/tongue swelling, widespread hives)

Contact instructions: [Clinic phone and hours; after-hours instructions; when to call clinic vs. seek emergency care]

Follow-up Plan

[Planned follow-up timing or PRN] [Staged treatment anticipated: yes / no; if yes, outline plan]

Provider Signature

Provider Signature: [Electronic signature/printed name]

Date/Time: [Date and time of signature]