Orthobiologics Injection Procedure Note (PRP)

Date/Time: [Procedure start date and time] | Patient: [Name and identifiers per local policy] | Procedure: [PRP injection to specific anatomic target with explicit laterality] (Laterality is required) | Operator: [Performing clinician] | Assistant: [Assistant name/role or "none"] | Setting: [clinic / ASC / hospital outpatient / other] | Guidance: [ultrasound-guided / landmark-guided]

Indication / Clinical Rationale

• [Diagnosis with specific anatomic structure and laterality, including chronicity and symptom pattern]
• [Prior treatments attempted and response] (If not available, state "not available")
• [Pertinent imaging findings supporting target selection with study type and date] (Note if previously reviewed rather than same-day; if not available, state "not available")
• [Baseline pain/function metrics] (If not measured, omit this line)

Pre-Procedure Safety Screen

• Allergies: [List relevant allergies including local anesthetics, antiseptics / no known allergies / not assessed]
• Bleeding risk/anticoagulants: [Medication(s) and last dose / none / not assessed]; Peri-procedural plan: [hold/continue per protocol or rationale]
• Infection screen: [No fever; no local cellulitis or wounds / positive findings and details / not assessed]
• Pertinent comorbidities: [e.g., diabetes, immunosuppression, coagulopathy / none / not assessed]

Informed Consent

• [Consent obtained from patient / surrogate] (Document surrogate authority if applicable)
• [Procedure explained, including injection of autologous PRP to target location with laterality]
• [Risks discussed: pain flare, bleeding/bruising, infection, neurovascular injury, vasovagal reaction, failure to improve] (Add site-specific risks as applicable)
• [Benefits, expected outcomes, and uncertainty of response discussed]
• [Alternatives reviewed: physical therapy, medications, other injections, surgery, no treatment]
• [Autologous nature of PRP explained]
• [Coverage/financial considerations discussed] (Include only if discussed)
• [Questions answered; patient agreed to proceed] (Note location of written consent form if obtained)
• [Direct patient quote regarding preferences or risk tolerance] (Include only if notable)

Time-Out

(Required: document immediately before the procedure)

• Verification: [Correct patient identity confirmed] | [Correct procedure confirmed] | [Correct site and laterality confirmed]
• Team members present: [Names and roles]

PRP Preparation

• Venipuncture site: [Location]
• Whole blood volume collected: [mL] | Anticoagulant: [Type and volume / none]
• Kit/device: [Manufacturer and model] | Processing: [single-spin / double-spin]; [Centrifuge parameters if known]
• Prepared by: [Clinician / staff role]
• PRP characterization: [leukocyte-rich / leukocyte-poor / not characterized]; [activated / non-activated] | Activation agent: [Agent and volume / none]
• Total PRP volume yielded: [mL]
• Platelet concentration: [Measured value and method / not measured]
• Local anesthetic in injectate: [Agent, concentration, volume mixed / none; used separately for skin anesthesia only]
• Lot/Expiration tracking:
  • PRP kit: [Manufacturer/model] | Lot: [lot] | Exp: [date]
  • Local anesthetic: [Agent/concentration] | Lot: [lot] | Exp: [date]
  • Activation agent: [Agent] | Volume: [mL] | Lot: [lot] | Exp: [date] (Include only if used)

Procedure Technique

• Patient positioning: [Position]
• Skin prep and sterile technique: [Antiseptic agent]; [Sterile gloves and drape]; [Sterile probe cover and gel] (Include probe cover for ultrasound-guided)
• Local anesthesia: [Agent, concentration, volume, route] (If used for skin/subcutaneous anesthesia)
• Guidance:
  • (If ultrasound-guided) Structures visualized: [List]; Needle visualization: [in-plane / out-of-plane]; Tip position confirmed at target: [yes / no]; Images saved to: [PACS / EHR]
  • (If landmark-guided) [Anatomic landmarks used]
• Injection targets: (Document each target separately with explicit laterality and PRP volume)
  • [Target structure with laterality]: Needle [gauge and length]; [Fenestration/peppering: yes / no]; [Aspiration: yes / no; findings if fluid obtained]; PRP injected: [mL]; Immediate outcome: [tolerated well / pain / other]
  • (Add additional targets as needed)

Findings / Complications

• Procedure status: [completed as planned / modified (specify) / aborted (reason)]
• Immediate patient response: [e.g., tolerated well, pain change, vasovagal symptoms]
• Complications: [None / describe complication and actions taken]
• Post-procedure neurovascular status: [Intact / findings] (Include for limb targets)

Post-Procedure Plan

• Expected course: [Soreness and potential inflammatory flare discussed]
• Activity restrictions: [e.g., relative rest 48–72 hours; sport-specific restrictions and timeframes]
• Weight-bearing: [As tolerated / specific restrictions] (Include for lower extremity targets)
• Wound care: [Bandage and bathing instructions]
• Medications: [Analgesia plan]; [NSAID avoidance: yes with duration / no restriction]
• Physical therapy: [Start date; protocol name or reference if provided]
• Red flags for return: [Fever, escalating redness/swelling, drainage, severe pain, neurological deficits]
• Follow-up: [Interval and modality]
• [Post-procedure instructions reviewed and provided in writing]

Required fields: explicit laterality and target structure; consent documentation; time-out completion; PRP volume injected per target (or "not injected" if aborted); explicit complications statement; post-procedure instructions. For unknown optional details, omit rather than inferring.