Peripheral Joint/Bursa Aspiration and/or Injection Procedure Note (Landmark or Non-Dedicated Ultrasound)

Date: [Date]    Time: [Time]

Location: [clinic / bedside / ED / procedure room]

Performing Clinician: [Name, credentials]

Patient Position: [supine / seated / lateral decubitus] (Include limb positioning if relevant)

Procedure Identification

Procedure Type: [aspiration only / injection only / aspiration with injection]

Target Structure and Laterality: [Specific joint or bursa with laterality and anatomic substructure] (Example format: "right knee suprapatellar pouch," "left subacromial-subdeltoid bursa")

Guidance Modality: [landmark-based (no ultrasound) / ultrasound-assisted] (If ultrasound-assisted, specify: [pre-scan localization / real-time guidance / confirmation]—select all that apply)

Indication

[Primary clinical reason] — [Clinical goal] (Limit to 1–2 sentences; include pain/effusion/suspected crystal disease/suspected infection/diagnostic anesthetic response and intended diagnostic or therapeutic aim)

Pre-Procedure Assessment

• Allergies: [local anesthetics / antiseptics / corticosteroids / none known] (List specifics if known; if unknown, state "unknown" with reason)
• Anticoagulant/Antiplatelet use: [agent and dose if known / none / unknown] (Include last dose timing if provided)
• Diabetes status: [yes / no / unknown] (Required if glucocorticoid planned)
• Skin at entry site: [intact / erythematous / infected-appearing / rash / open wound / other]
• Prosthetic joint at target: [yes / no / unknown]

Contraindications: [No contraindications identified / specify concern and decision made]

Consent

Consent obtained from [patient / surrogate (specify relationship)]. Discussion included the nature of the procedure, intended benefits, alternatives including no procedure, and material risks (bleeding, infection, pain, vasovagal reaction; steroid-specific risks such as transient flare or hyperglycemia if applicable). Consent type: [verbal / written] per local policy. Patient had opportunity for questions and agreed to proceed. (Required attestation—do not infer)

Time-Out and Site Verification

Time-out performed confirming correct patient, procedure, site with laterality, and positioning. Site marking: [performed / not required per policy / declined per policy]. (Required attestation—do not infer)

Sterile Preparation

• Hand hygiene performed.
• Skin prep: [alcohol / chlorhexidine / povidone-iodine]; adequate drying time observed.
• Draping: [sterile drape used / not used per local standards].
• Gloves: [sterile / clean] per local standards.

Anesthesia

[None / Topical anesthetic (specify) / Vapocoolant (specify) / Local infiltration: agent, concentration, volume, route] (Example format: "lidocaine 1%, 3 mL subcutaneous")

Technique

[Approach/entry site description and named approach if standard]. Needle: [gauge]G, [length]. [Confirmation of placement: free aspiration of fluid / lack of resistance on injection / ultrasound visualization of needle tip]. [Number of attempts if more than one]. Patient tolerance: [well tolerated / mild discomfort / other].

Ultrasound Documentation

(Include this section only if ultrasound was used; select ONE pathway below. If ultrasound not used, omit this section entirely or state "Ultrasound: not used" per local preference)

If permanent image recording and reporting: Indication for ultrasound: [difficult anatomy / small effusion / vessel avoidance / other]. Pre-scan findings: [effusion presence and size / optimal entry point / other relevant findings]. Real-time guidance with needle visualization: [yes / no]. Images/clips saved to [medical record / PACS]. Focused ultrasound guidance report included.

If no permanent recording: Limited ultrasound used for [localization / assistance]; images not permanently recorded. This was not a comprehensive diagnostic ultrasound examination. Ultrasound contribution: [site selection / vessel avoidance / effusion confirmation / other].

Aspiration Findings

(Include this section only if aspiration was attempted)

• Successful aspiration: [yes / no]
• Volume obtained: [mL]
• Gross appearance: [clear/straw-colored / cloudy / purulent / bloody/hemorrhagic / viscous / other]
• Specimen sent for analysis: [yes / no]. If yes, studies ordered: [cell count with differential / crystal analysis / Gram stain / aerobic culture / anaerobic culture / AFB / fungal / cytology / other]. (If infection or crystal disease suspected and studies not sent, document reason)
• If unsuccessful: [Suspected reason] (Avoid over-speculation)

Injection Details

(Include this section only if injection was performed; repeat the block below for each injection site if multiple)

• Injection location: [intra-articular / bursal / peri-tendinous] — [anatomic target with laterality]
• Sequence: [aspiration preceded injection / injection only]. Same needle tract used: [yes / no / N/A].
• Medications injected:
  • [Medication generic name], [formulation], [concentration], [dose in mg], [volume in mL]; mixed with [diluent or local anesthetic and volume] if applicable.
  • (Add additional medications as separate entries if applicable)

Complications

[None / specify complication]. (If complication occurred, document immediate management and patient stability. Always complete—do not omit or infer)

Post-Procedure Assessment

• Immediate tolerance: [well tolerated / mild discomfort / other].
• Post-procedure pain or functional change: [score or description if collected / not assessed].
• For diagnostic anesthetic response: [expected assessment window and criteria for positive response]. (Include only if applicable)
• For therapeutic injections: [expected onset of effect and symptoms that should prompt follow-up]. (Include only if applicable)

Aftercare and Return Precautions

Instructions reviewed with patient. Wound care: [keep site clean; dressing instructions if applied]. Activity: [avoid overuse for 24 hours; avoid prolonged immobilization]. Symptom management: [ice as recommended; simple analgesia as needed]. (If glucocorticoid given, warn about possible transient flare. If patient has diabetes and received glucocorticoid, advise glucose monitoring for 1–3 days)

Return precautions reviewed: fever or chills; increasing redness, warmth, or swelling; drainage from the site; escalating pain; inability to bear weight or use the limb; new neurologic symptoms; uncontrolled bleeding.

Follow-Up

Planned follow-up: [interval] with [responsible clinician or team].

Laboratory results: [Results to be communicated via (method) within (timeframe) / no studies sent]. Time-sensitive results: [specify or N/A]. (Include only if specimen sent)