Microneedling Procedure Note

Date: [Procedure date and time]

Patient: [Patient name and at least one additional identifier]

Provider: [Provider name and credentials]

Location: [Clinic/facility name and site]

Procedure: Microneedling

Procedure Summary

[Brief 3–5 sentence synopsis including: indication and treatment intent; areas treated; device type; anesthesia approach; key parameters such as needle depth range; complications—state "none" explicitly if none occurred; and patient tolerance]

Indication & Treatment Intent

• Primary indication/diagnosis: [e.g., acne scarring, dyschromia, rhytides, striae, alopecia]
• Treatment intent: [cosmetic / medical-functional]
• Baseline severity/description: [Baseline severity or grading if documented]
• Session number: [Session number of planned series / single session]

Pre-Procedure Assessment

• Prior microneedling or energy-based treatments: [History and any complications / None / Not assessed]
• Scarring tendency (keloid/hypertrophic): [Present / Absent / Not assessed]
• Fitzpatrick skin type or pigmentary risk: [Type or risk assessment / Not assessed]
• HSV history: [Positive / Negative / Not assessed]; Prophylaxis plan: [Plan / Not applicable]
• Recent isotretinoin use: [Timing and decision rationale / None / Not assessed]
• Allergies: [Topical anesthetics / Antiseptics / Nickel / Other / None reported / Not assessed]
• Anticoagulant/antiplatelet use: [Agent(s) / None / Not assessed]
• Pregnancy status: [Status / Not applicable / Not assessed] (Include if treating abdomen/breasts or using large-area topical anesthetic.)

Informed Consent

[Consent documentation] (State that risks, benefits, and alternatives were discussed and questions answered. Include specific risks reviewed: expected effects—erythema, edema, pinpoint bleeding, transient dryness; procedural risks—infection, HSV reactivation, post-inflammatory hyperpigmentation, scarring, allergic reactions, acne flare; and device-specific risks if applicable—thermal injury for RF microneedling. Document that the patient agreed to proceed and received post-care instructions. Note photography consent if images taken. Do not infer consent from a signed form—explicitly document the discussion occurred.)

Safety Time-Out

[Time-out attestation] (Confirm: patient identity verified with two identifiers, procedure and treatment areas confirmed, allergies reviewed, eye protection confirmed, sterile single-use needle tip verified. A single attestation line is acceptable.)

Anesthesia

• Topical anesthetic: [Product name and concentration]; [Amount applied (g or mL)]; [Surface area covered]; [Application method: with/without occlusion]; [Application time: start to removal]; [Dwell time]; [Adverse effects: None / describe] / [Not used]
• Local infiltration: [Agent, concentration, volume, epinephrine yes/no, injection sites] / [Not performed]

Skin Preparation & Asepsis

• Pre-cleansing: [Agent/method / Not performed]
• Antiseptic: [Agent]; [Dry time observed]
• Needle cartridge/tip: Sterile single-use confirmed; [Sharps disposal method]
• PRP/biologics handling: [Phlebotomy site prep and closed-system handling] / [Not applicable]

Device & Settings

• Device type: [manual roller / automated pen / RF microneedling]
• Manufacturer & model: [Device make/model]
• Needle configuration: [Needle count; for RF: insulated / non-insulated]
• Tip/cartridge: [Lot number]; [Expiration date] (Required when biologics or PRP used.)
• RF parameters: [Energy level]; [Pulse duration]; [Mode] / [Not applicable]

(Do not carry forward settings from prior notes without explicit confirmation.)

Treatment Parameters by Zone

(Depth by zone must be explicitly documented. Use standardized endpoints: uniform erythema; pinpoint bleeding—uniform or scattered; edema/wheal.)

Anatomical Zone	Needle Depth (mm)	Speed Setting	Passes	Endpoint Achieved	Notes
[Zone]	[Depth]	[Speed / N/A]	[Number]	[uniform erythema / pinpoint bleeding—uniform / pinpoint bleeding—scattered / edema/wheal]	[Adjustments, precautions, or avoidances]
[Zone]	[Depth]	[Speed / N/A]	[Number]	[Endpoint]	[Notes]
[Zone]	[Depth]	[Speed / N/A]	[Number]	[Endpoint]	[Notes]

Adjuncts Applied

[Product name]; [Timing: pre-needling / during / post-needling]; [Amount]; [Lot number]; [Expiration] / None

(If biologics or PRP used, lot/expiration required. Note if patient was counseled that product is not specifically approved for intradermal delivery.)

Intra-Procedure Course

• Patient tolerance: [Pain score 0–10 or narrative description]
• Hemostasis measures: [Method used / None required]
• Procedure modifications: [Modification and rationale / None]
• Complications: [No complications / Description, management, and patient status]

Immediate Post-Procedure Condition

• Observed skin findings: [Erythema extent, edema, pinpoint bleeding status]
• Overall patient condition: [Stable / Other]
• Post-procedure photos: [Taken / Not taken]

Post-Care Instructions

[Instructions summary] (State that written instructions were provided and name the handout if standardized. Summarize key guidance given: sun protection and sunscreen timing; avoidance period for retinoids/acids/exfoliants; makeup avoidance window; swimming/sauna/sweating restrictions; allowed skincare; expected course and timeline; return precautions—fever, increasing pain, purulence, expanding redness, vesicles/blistering; and contact instructions.)

Medications

• Antiviral prophylaxis: [Agent, dose, frequency, duration] / [Not prescribed]
• Post-procedure topicals: [Product(s) and instructions] / [None]
• Analgesia: [Recommendation] / [None]

Follow-Up Plan

• Follow-up timeframe: [Timeframe]
• Next session: [Interval and sessions remaining] / [Not applicable]
• Escalation plan: [Contact instructions for adverse events]

Signature

Clinician Signature: [Signature or electronic attestation]

Credentials: [Credentials]

Date/Time: [Date and time of signature]