Sclerotherapy Procedure Note

Date of service: [Date of service]

Procedure time: [Start–End time / Single timestamp]

Location: [Office / Outpatient clinic / Procedure suite / Other: specify]

Performing clinician: [Name, credentials]

Patient positioning: [Supine / Standing / Prone / Lateral decubitus / Multiple positions: specify]

Laterality and regions treated: [Right / Left / Bilateral / N/A]; [Regions treated] (Laterality must never be omitted—enter "N/A" if not applicable.)

Indication

[Indication summary] (Write 2–4 sentences specifying: (1) whether the indication is symptomatic—list specific symptoms—or cosmetic-only, explicitly stating symptoms are absent; (2) target vessel type: telangiectasias/spider veins vs reticular veins; and (3) clinical diagnosis statement, e.g., "[Anatomic region] telangiectasias; planned sclerotherapy session #[number]".)

Pre-Procedure Assessment

History

• Prior venous treatments/outcomes: [Details] (Use "denies prior treatment" if none.)
• Thrombotic history and risk factors: [DVT/PE history; thrombophilia; active cancer; recent immobility/surgery] (Use "denies" or "no history of" rather than leaving blank.)
• Medications: [Anticoagulants/antiplatelets; estrogen therapy; other relevant medications]
• Pregnancy/lactation: [Pregnant / Not pregnant / Lactating / Not applicable]
• Allergies: [Allergen(s) and reaction(s)] (State "No known drug allergies" if appropriate.)
• Relevant comorbidities: [Conditions affecting wound healing or thrombosis risk]

Exam

[Focused exam findings] (Describe skin integrity over planned injection sites and distribution/extent of target veins by limb and region.)

Duplex Ultrasound Status

[Duplex performed / Duplex not performed]; [Findings or rationale] (If performed: summarize deep venous patency, reflux findings, feeder identification. If not performed: provide rationale—e.g., limited cosmetic disease, no clinical suspicion for reflux, recent duplex on file.)

Consent

[Consent documentation] (Confirm written and verbal informed consent obtained; risks discussed including hyperpigmentation, matting, pain/bruising, skin injury/ulceration/necrosis, DVT/PE, allergic reactions, cosmetic outcome uncertainty, and need for multiple sessions; alternatives reviewed. Reference location if documented elsewhere.)

Procedure Details

Time-Out

[Time-out attestation] (Attest that verification confirmed patient identity, correct procedure, correct site/laterality, allergies reviewed, and correct sclerosant available.)

Vein Mapping

[Mapping method]: [Visual inspection / Transillumination / Ultrasound guidance]; performed [standing / supine]. [Target areas marked by leg and region]. (Reference baseline photographs or diagrams if obtained.)

Preparation

[Skin prep; patient position during injections; local/topical anesthetic if used]

Sclerosant

[Sclerosant name]; [Concentration]; [Liquid / Foam]; [Total volume]; [Volume per injection or number of sites]; session maximum [not exceeded / exceeded: explain]. (If foam, include preparation method and gas:liquid ratio.)

Lot/Expiration: [Lot number and expiration] (If not recorded, state "Not recorded in this note".)

Technique Narrative

[Injection technique description] (Include needle gauge, entry approach, method of intravascular confirmation, injection endpoints observed.)

Extravasation: [None observed / Present: location, volume, management] (Must be explicitly documented.)

Adjunct Procedures

[Adjunct procedures if performed] (Document any microthrombectomy, aspiration of retained blood, or topical therapy. Omit section if none.)

Immediate Post-Procedure Status

Tolerance: [Patient tolerance]

Skin findings: [Immediate findings at injection sites]

Observation: [Neuro/respiratory status]; [Observation duration]

Medications administered: [Medications given / None]

Complications: [No complications observed / Complication(s) and management] (This statement must always be present.)

Post-Procedure Plan

Compression

[Compression type: wrap / stocking]; [Level: knee-high / thigh-high]; [Compression class if known]; [Timing: continuous wear period, then daytime-only period]. (If declined, document patient decline and counseling provided.)

Activity Guidance

[Activity counseling] (Early ambulation encouraged; avoidance of heavy exercise, hot baths/sauna, prolonged immobility, and sun exposure on treated areas for recommended period.)

Return Precautions

[Urgent/emergency warnings documented] (Must include: progressive leg swelling/pain suggestive of DVT, chest pain or shortness of breath, severe pain or skin changes at injection sites, signs of allergic reaction.)

Monitoring and Follow-Up

Risk factors: [Patient-specific thrombosis/skin risk factors]

Follow-up: [Interval and purpose: response assessment, trapped blood evaluation, next session planning]; [Imaging or referral orders if applicable]

(If any required element is unavailable, document as "Not documented" rather than omitting.)