Tendon Sheath/Ligament Injection Procedure Note

Date and Time: [Date and time]

Patient Name: [Full name]

DOB: [Date of birth]

MRN: [Medical record number]

Clinician: [Name, degree/credentials]

Procedure: [Specific procedure name]

Anatomic Site: [Specific site and digit/location details]

Laterality: [Right / Left] (Never infer. Document bilateral procedures separately.)

Guidance Method: [Landmark / Ultrasound-guided]

(Do not finalize if Laterality, Anatomic Site, or Medication details are incomplete. Prompt for completion before signing.)

Indication

[Diagnosis prompting injection] [Key symptoms and functional impact] [Relevant prior conservative treatments and response] [Pertinent comorbidities affecting procedural risk, e.g., diabetes, anticoagulation] (Include comorbidities only when they alter risk or management.)

Consent

[Consent obtained from patient / surrogate]. Discussed procedure purpose, expected benefits, material risks, and alternatives; questions answered; patient agreed to proceed. Material risks discussed included [bleeding, infection, steroid flare, skin/fat atrophy or discoloration, tendon or fascia weakening, transient hyperglycemia, nerve or vessel injury] (Tailor to specific injection and patient factors.) [Written / Verbal] consent obtained per institutional policy.

Time-Out

Time-out performed immediately prior to procedure confirming correct patient, procedure, anatomic site, and laterality.

Ultrasound Guidance

(Include only when ultrasound guidance was used. Omit entire section for landmark-only procedures.)

• Ultrasound used for real-time needle guidance
• Target confirmed: [tendon sheath / perifascial plane / periligamentous plane / other specified structure]
• Transducer: [Type and frequency]
• Approach: [In-plane / Out-of-plane]
• Needle tip visualization confirmed
• Representative images archived per policy

Procedure

Positioning: [Patient position] [Limb/digit positioning and support]

Skin Preparation: [Prep agent] [Glove type]

Anesthesia: [Local anesthetic agent, concentration, volume] (If no separate local used, state "No pre-injection anesthesia" or "Anesthetic mixed with injectate.")

Needle and Equipment: [Needle gauge and length] [Syringe size]

Approach: [Entry point relative to landmarks] [Target plane: intrasheath / perifascial / periligamentous] (For tendon sheath injections, document intent to avoid intratendinous placement.)

Aspiration: [Result, e.g., "Negative for blood"] (Omit if aspiration not performed.)

Medications Injected:

• [Drug name], [concentration], [volume in mL], [total dose in mg]
• (Add line for each medication. Never infer medication details.)

Immediate Result: [Patient tolerance] [Immediate symptom or mechanical change if assessed]

Post-Procedure

Diagnosis: [Confirmed post-procedure diagnosis]

Complications: [None / Description with immediate management]

EBL: [Minimal / None]

Dressing and Condition: [Dressing applied or none] [Patient condition at completion]

Aftercare and Follow-Up

• Expected course: [Anesthetic wear-off timing, possibility of steroid flare within 24–48 hours]
• Activity: [Avoid heavy use/strain for specified period; gradual return as tolerated]
• Pain management: [Ice, acetaminophen/NSAIDs as appropriate]
• Red flags requiring return: [Increasing pain/redness/swelling, fever, drainage, new numbness or weakness]
• Glucose monitoring: [Instructions if diabetic received steroid] (Include only for diabetic patients.)
• Follow-up: [Timing or criteria for reassessment]

(Documents instructions discussed with patient; not a patient-facing handout.)

Signature

[Clinician signature and credentials]