Therapeutic Botulinum Toxin Injection (Chemodenervation) Procedure Note

Date of Service: [Date]

Location: [Clinic/facility name and type]

Proceduralist: [Name and credentials]

Interpreter Used: [Language and modality] (Only include if applicable; otherwise omit this line.)

Procedure Identification

Procedure: Therapeutic botulinum toxin injection (chemodenervation).
Target region(s): [Anatomic region(s) and muscle groups, including laterality]
Primary diagnosis/indication: [Diagnosis]
Treatment course: [Initial / Repeat]. (If repeat, include date of last injection and prior product used; state "not available" if unknown.)

Indication and Goals

Clinical condition: [Description of condition and affected function]
Functional/symptom burden: [Specific impairments justifying treatment] (Include only items explicitly relevant today.)
Relevant prior treatments: [Therapies, orthotics, medications, procedures] (Include only if pertinent to today's decision.)

Goals:

• Primary goal: [Specific, measurable goal tied to targeted muscles and functional outcome]
• Secondary goal(s): [Additional measurable goals] (Include up to 2-3 if applicable.)

Baseline measures: [Quantifiable baseline measures] (If unavailable, state "not available.")
Planned reassessment timepoint: [Timeframe and method for measuring goal attainment]

Prior Response

(Include this section only for repeat treatments. Omit entirely for initial treatments.)

Observed benefit domains: [Areas of improvement] (Label patient-reported information as such.)
Onset and duration of effect: [Onset timeframe] / [Duration until wear-off]
Prior adverse effects: [None / Description including severity and course]
Adjustments based on prior response: [Changes to dose, muscles, technique, or interval]

(If prior response details are unknown, document "Prior response not available in record today" and omit the fields above.)

Consent and Safety Verification

Informed consent obtained after discussion of risks, benefits, alternatives, and expected outcomes. Risks discussed included local pain, bruising, bleeding, unintended weakness, and infection. [Risks of dysphagia, voice changes, breathing difficulties, and systemic spread were also discussed.] (Include preceding sentence when relevant to injection pattern.) Alternatives were reviewed, and the patient agreed to proceed. [Off-label use was discussed and accepted.] (Include only if off-label use applies.) Immediately prior to injection, a time-out was performed confirming correct patient, procedure, and site/laterality.

Product and Preparation

(If multiple vials were used, document each and reconcile totals.)

• Product: [Brand and nonproprietary name]
• Vial size: [Units per vial]
• Lot number: [Lot number] (If truly unavailable, document "not available.")
• Expiration date: [Date]
• Dilution: [Diluent type], [Volume added per vial], final concentration [Units/mL]
• Dose accounting: Total prepared: [Units]; Total administered: [Units]; Total discarded: [Units] ([Reason]). (Administered + discarded must equal prepared.)

Localization Method

Guidance used: [Anatomic landmarks/palpation / EMG / Electrical stimulation / Ultrasound] (Select all that apply.)
EMG details: [Muscles localized with EMG assistance] (Include only if EMG was used.)
Ultrasound details: [Probe and key structures visualized]; images saved per facility policy: [Yes / No] (Include only if ultrasound was used.)

Technique

Positioning: [Patient position]
Aseptic preparation: [Skin prep agent]; sterile technique maintained.
Comfort measures: [Ice / Topical anesthetic / Local anesthetic / Distraction / None]
Needle: [Gauge] gauge, [Length] (Specify longer needle for deep muscles as applicable.)

Injection Distribution

(List each injected muscle. Total units must reconcile with dose accounting above.)

Muscle	Laterality	Number of Sites	Units	Comments
[Muscle name]	[R / L / Bilateral]	[Number]	[Units]	[Optional: atrophy, fibrosis, limited tolerance, etc.]
[Muscle name]	[R / L / Bilateral]	[Number]	[Units]	[Comments]
Total Units Administered			[Total]

Planned but not completed: [None / Muscles not injected and reason]

Tolerance and Complications

Overall tolerance: [Tolerated well / Tolerated with mild discomfort / Tolerated with moderate discomfort]
Immediate adverse events: [None / Description of bleeding, hematoma, vasovagal symptoms, allergic symptoms, or other]
Estimated blood loss: Minimal. (Specify volume if greater than minimal.)

Follow-Up Plan

Reassessment timing: [Timeframe] to evaluate goal attainment and adjust treatment as needed.
Outcome measurement: [Measures aligned with goals above]
Rehabilitation coordination: [PT/OT plan including stretching, strengthening, motor retraining, splinting]
Orthotics/equipment: [Adjustments or new equipment needs] (Include only if applicable.)
Repeat injection window: [Anticipated interval] (Include if ongoing treatment is planned.)
Return precautions: Patient instructed to seek urgent evaluation for difficulty swallowing, breathing, speaking, or generalized weakness.