Radiofrequency Microneedling Procedure Note

Date/Time: [Date; Start time – End time]

Location: [Facility and room]

Patient: [Patient identifier per policy]

Performing Clinician: [Name and credentials]

Session: Session [#] of [# planned]; [Series name if applicable]

Device: [Manufacturer; model; tip/cartridge type]; new single-use tip confirmed

Procedure Summary

[Concise summary of procedure performed, anatomic area(s) treated, indication/goal, session number, anesthesia type, and immediate tolerance] (Write in 1–3 sentences.)

Indication and Treatment Plan

[Primary indication(s) and treatment objectives; relevant prior treatments and response if applicable; planned treatment course with number of sessions and typical interval]

Pre-Procedure Assessment

Safety and eligibility screen:

• History of keloid or hypertrophic scarring: [Denied / Reported / Not assessed (reason)]
• Active infection in treatment field: [Not present / Present (details)]
• HSV history (if treating perioral/perinasal areas): [Denied / Positive history (prophylaxis plan) / Not applicable]
• Immunosuppression: [Denied / Present (details)]
• Bleeding risk or anticoagulant use: [Denied / Present (agent and plan)]
• Recent isotretinoin use: [Denied / Reported (date discontinued)]
• Active inflammatory skin condition in treatment area: [Not present / Present (details)]

Treatment field examination: [Findings including active lesions, wounds, dermatitis, sunburn, tan, baseline pigmentary concerns] (Document "Not present" if none.)

Baseline photographs: [Obtained / Not obtained (reason)]

Informed Consent

Informed consent obtained from [patient / legal guardian]. The nature of the procedure, anticipated benefits, material risks, alternatives, and opportunity for questions were discussed; all questions were answered and consent was signed prior to the procedure.

Material risks discussed included: thermal injury/burns; scarring (hypertrophic or atrophic); pigmentary changes (hyperpigmentation or hypopigmentation); infection including HSV reactivation where relevant; prolonged erythema or edema; pain; subcutaneous fat loss or contour change; and nerve injury or sensory changes.

Alternatives discussed included: no treatment, topical regimens, laser treatments, chemical peels, injectables, and surgical options.

Adjunct treatment: [Product(s) used; route and timing]. Patient informed that this combination use is not specifically FDA-cleared; risks, benefits, and alternatives of combination use were discussed. (Include only if adjunct treatment was used; otherwise omit this line.)

Verification and Time-Out

Pre-procedure verification performed confirming correct patient, correct procedure, correct treatment site(s), and correct device/tip available. Time-out performed immediately prior to procedure at [time] with confirmation of patient identity, procedure, and treatment site(s).

Anesthesia

[No anesthesia used / Topical anesthesia / Local infiltration / Nerve block / Other]: [Agent(s), concentration, amount or "applied per protocol," application duration, and tolerance] (If no anesthesia used, state only "No anesthesia used.")

Procedure Details

Preparation

Skin prepared with [cleansing agent]. [Sterile / Clean] technique employed. PPE used per protocol. New single-use needle cartridge opened and placed; disposed of in sharps container post-procedure. [Conductive gel or topical applied prior to treatment, if any]

Device Settings

RF delivery mode: [Monopolar / Bipolar / Fractional / Device-specific mode]. Special features utilized: [Vacuum / Pulse stacking / Impedance feedback / Cooling / None].

Treatment Parameters by Zone

(Document one entry per zone treated. If a planned zone was skipped, document "Skipped" with reason. Omit zones that were neither treated nor planned.)

• [Zone name]: Needle depth [#] mm; Energy [device level and/or physical units]; Pulse duration [# ms] (if applicable); Passes [#]; Pulse count/density [approximate]; Clinical endpoint [uniform erythema / mild edema / pinpoint bleeding / other]
• [Zone name]: Skipped; Reason: [reason] (Include only for planned zones that were skipped.)

(Standard zones: Forehead, Temples, Periorbital upper, Periorbital lower, Nose, Cheeks malar, Cheeks medial, Perioral, Chin, Jawline, Submentum, Anterior neck, Other)

Endpoints and Safety Monitoring

Total passes performed: [#]. Zone-specific reductions or modifications: [Details or "None"]. Endpoints used to guide treatment: [uniform erythema / avoidance of whitening or graying / avoidance of blistering]. Burn-risk mitigation: [reduced settings on thin/bony areas / avoided excessive overlap / cooling time between passes / not applicable]. Post-procedure inspection: [No blistering, focal epidermal injury, unexpected whitening, or char observed / Findings if present].

Immediate Post-Procedure Status

Patient stable; pain level [#/10]. Skin appearance: [expected erythema and edema; pinpoint bleeding resolved / other findings]. Dressings/topicals applied: [list or "None"]. Disposition: [Home; with escort / Home; unaccompanied / Other].

Complications

[None] (This section is required. If complications occurred, document: complication, timing, management provided, prescriptions or referrals, and patient counseling with return precautions.)

Aftercare and Follow-Up

Written post-procedure instructions provided; patient verbalized understanding. Return precautions reviewed: blistering, increasing pain, expanding redness, purulent drainage, fever, new sensory changes, suspected HSV outbreak.

Next follow-up: [Date/time or target interval]. Next treatment session: [Timing/interval or "N/A if final session"]. Planned parameter adjustments for next session: [Details or "None"].