Phenol Neurolysis Procedure Note

Procedure: Phenol Neurolysis

Date/Time: [Start time] – [End time]

Location: [Procedure location]

Patient: [Patient name], [DOB], [MRN]

Performing Clinician: [Name, credentials]

Supervising Clinician: [Name, credentials / Not applicable]

Procedure Summary: [One-line summary including laterality and target nerve(s)]

Indication and Goals

[Primary indication for neurolysis] (State the main clinical reason such as focal spasticity impacting function, hygiene, positioning, bracing tolerance, or pain from spasm.)

[Patient-specific functional goals and baseline assessment] (Include explicit goals relevant to the targeted muscles/nerve distribution, brief rationale for choosing phenol over alternatives if relevant, and prior spasticity management tried. When available, include baseline tone measures, relevant ROM limits, functional status, and pain score if pain is an indication.)

Pre-Procedure

• Allergies: [Phenol allergy status] | [Local anesthetic allergy status] | [Antiseptic allergy status] (Explicitly document findings for each; do not leave blank.)
• Anticoagulation Status: [Medication(s) and indication] | [Last dose/date if relevant] | [Peri-procedural plan: proceed / hold / bridging] (Must be explicitly documented; do not infer from silence.)
• Skin Inspection: [Entry site assessment findings]
• Baseline Neurologic Exam: [Sensation findings] | [Strength findings] (Include especially for mixed nerve targets.)
• Informed Consent: [written / verbal] consent obtained from [patient / surrogate with relationship]. Discussed: procedure nature, expected benefits linked to stated goals, material risks (dysesthesia, neuropathic pain, weakness, hematoma, infection, incomplete effect), and alternatives (therapy, orthotics, oral medications, botulinum toxin, surgery, no treatment). [Consent form location if applicable] (Required; do not finalize note without consent documentation.)
• Time-Out Performed: [Yes] – Patient identity, procedure, laterality, target nerve(s), allergies, and equipment/medication availability verified immediately prior to needle insertion. (Required; do not finalize note without time-out documentation.)

Procedure Details

Positioning: [Patient position] | [Limb positioning for access]

Skin Preparation: [Prep agent] | [Sterile / clean technique]

Local Anesthetic: [Agent, concentration, dose, volume, site / None]

Sedation: [Agent(s), dose(s), route, monitoring, responsible clinician / No sedation]

Localization Method: [Modalities used and key parameters] (For ultrasound: probe type, key landmarks, approach. For electrical stimulation: current, pulse width, frequency, motor response confirming target. Include EMG or fluoroscopy details only if used.)

Phenol Solution: [Formulation: aqueous / glycerin] | [Concentration: %] | [Total volume: mL] (Required fields; do not leave as placeholders.)

Needle: [Type, gauge, length] | [Approach description]

Injection Log:

Laterality	Nerve/Branch	Localization Method	Confirmation Finding	Phenol Concentration	Volume (mL)	Tolerance/Adverse Symptoms
[Left / Right]	[Target nerve/branch]	[Ultrasound / E-stim / EMG / Fluoro]	[Motor response or landmark]	[%]	[mL]	[Tolerated well / symptoms noted]

(Add one row per nerve/branch targeted.)

Procedure Course: [Completed as planned / Partially completed / Aborted]. [Targets completed and reason for discontinuation if applicable]

Immediate Assessment

• Patient Tolerance: [Tolerance/comfort level]
• Immediate Tone Change: [Qualitative description and/or scale]
• Passive ROM Change: [ROM changes if assessed / Not assessed]
• Pain Change: [Pain response if relevant indication / Not applicable]
• Functional Observation: [Observation performed / Not assessed] (Note: reflects immediate anesthetic effect, not full neurolytic effect.)
• Neurovascular Check: [Pulses, strength, sensation findings] (Especially important for mixed nerve targets.)
• Dressing: [Dressing applied]
• Bleeding/Hematoma: [Assessment findings]
• Complications: [None / Complication(s) and management] (Must be explicitly documented; do not infer from silence.)

Plan

Therapy: [PT/OT referral with objectives and timing / Not indicated]

Orthotics/Bracing: [Orthotist referral, device adjustments, skin check instructions, follow-up fitting plan / Not indicated]

Medications: [Antispasticity regimen adjustments, analgesia plan if needed]

Follow-up: [Timeline and provider] | [Outcomes to reassess] | [Contingency for delayed adverse effects]

Patient Counseling: Counseled on expected time course (immediate local anesthetic effect vs delayed neurolytic effect over days) [and activity precautions if applicable].

Attestation

[Operator signature, credentials, date/time]

[Supervising clinician attestation if trainee involved] (Per institutional policy.)