TMJ Arthrocentesis/Injection Procedure Note

Procedure: [Procedure type: arthrocentesis with lavage / intra-articular injection / both]; [Laterality: right / left / bilateral]; [Injectate(s) if any] (Never infer laterality or medication names; if unspecified, leave blank with a flag for clarification.)

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

Location: [Clinic / ASC / OR / other: specify]

Proceduralist: [Primary operator name, credentials]; [Assistant(s) if present: name(s), credentials]

Patient: [Name] | [DOB] | [MRN]

Indication and Diagnosis

[Clinical indication(s) for TMJ procedure, including relevant symptoms, functional limitations, duration, and severity if documented] [Brief reference to prior imaging if it informed decision-making] (Do not reproduce full imaging reports.)

Pre-Procedure Diagnosis: [Diagnosis]
Post-Procedure Diagnosis: [Diagnosis] (State explicitly if same as pre-procedure or document any changes.)

Informed Consent

[Written / Verbal] consent obtained from [patient / legal representative: relationship and authority]. The nature of the procedure, expected benefits, alternatives (including non-procedural options), and material risks were discussed. Patient questions were answered and consent confirmed per policy. Risks discussed included: [bleeding/hematoma, infection, swelling/extravasation, transient facial nerve weakness or paresthesia, ear symptoms, malocclusion sensation, pain flare, possible need for repeat procedure or surgical escalation]. (Include at minimum the risks listed; add others if discussed.)

Pre-Procedure Baseline

Pain: [VAS or NRS score; at rest and/or with function] (Omit line if not obtained.)
Maximum Interincisal Opening: [MIO in mm]; [pain-limited / assisted / unassisted] (Omit line if not obtained.)
[Additional baseline measures if documented: lateral excursion, joint sounds] (Include only if clinically relevant.)

Anesthesia and Medications

Allergies reviewed: [Yes / No]; [Details if relevant]
Local anesthesia: [Agent], [concentration], [volume], [site: e.g., auriculotemporal nerve block, local infiltration] (State explicitly if only local anesthesia was used.)
Sedation: [None / Minimal / Moderate / Deep / General]; [Responsible provider if applicable] (If sedation provided, reference anesthesia record for detailed medication documentation.)

Time-Out and Site Verification

Time-out performed immediately prior to needle entry: [Yes / No] (If No, document reason and alternative safety steps taken.)
Verified correct patient, procedure, and site/laterality: [Yes / No]
Site marking performed: [Yes / No / N/A]

Procedure Details

Positioning: [Supine / Semi-recumbent / Other]
Skin prep: [Agent]; sterile technique maintained

Right TMJ

(Include for right-sided or bilateral procedures; remove for left-only procedures. Laterality must never be inferred.)

• Approach and Access: [Single-needle / Double-needle] technique; Needle: [Gauge], [Length]; Landmarks/guidance: [Anatomic landmarks / Ultrasound / Other]; [Note any access difficulty]
• Arthrocentesis/Lavage: [Performed / Not performed; injection only] (If performed: Irrigation solution: [type]; Total volume: [mL]; Effluent: [clear / blood-tinged / debris]; Extravasation: [none / describe])
• Intra-Articular Injection: [Performed / Not performed] (If performed, list each medication: [Name, concentration, dose, volume] → [additional medications if any]; note if injection followed lavage) (Never infer medication details.) [Lot/expiration if required by policy]

Left TMJ

(Include for left-sided or bilateral procedures; remove for right-only procedures. Laterality must never be inferred.)

• Approach and Access: [Single-needle / Double-needle] technique; Needle: [Gauge], [Length]; Landmarks/guidance: [Anatomic landmarks / Ultrasound / Other]; [Note any access difficulty]
• Arthrocentesis/Lavage: [Performed / Not performed; injection only] (If performed: Irrigation solution: [type]; Total volume: [mL]; Effluent: [clear / blood-tinged / debris]; Extravasation: [none / describe])
• Intra-Articular Injection: [Performed / Not performed] (If performed, list each medication: [Name, concentration, dose, volume] → [additional medications if any]; note if injection followed lavage) (Never infer medication details.) [Lot/expiration if required by policy]

Findings

(Include only if notable procedure-related observations; omit section entirely if none. Label any interpretation clearly as impression.)

[Notable findings: e.g., improved translation after manipulation, bloody effluent, significant extravasation, technical difficulty] [Impression if applicable]

Complications

Complications: [None / Describe: include timing, severity, and immediate management] (This section must always be completed. Common complications: fluid extravasation/swelling, transient facial nerve weakness, minor bleeding/hematoma, ear fullness, dizziness/vertigo.)
Patient status at end of visit: [Stable / Other]

Estimated Blood Loss

[Minimal / Estimated volume in mL]

Immediate Post-Procedure Status

Pain: [VAS or NRS score] (Omit if not obtained.)
MIO: [mm] (Omit if not obtained.)
Immediate symptoms: [None / ear fullness / dizziness / facial weakness / other]
Condition: [Awake, alert, stable / Other]; Facial nerve function: [Intact / Concern noted: describe]

Disposition and Follow-Up

Disposition: [Home / PACU / Observation]
Follow-up: [Timeframe and visit type]
Return precautions reviewed: fever, worsening swelling/redness, drainage, severe or worsening pain, persistent facial weakness or numbness, hearing changes, persistent vertigo, difficulty breathing/swallowing

Post-Procedure Instructions

• Diet: [Soft diet duration if applicable]
• Jaw rest: [Guidance and duration]
• Thermal therapy: [Ice / Heat; schedule]
• Pain management: [Medications and dosing instructions]
• Home exercises: [Provided verbally / written handout; start date; frequency] (Omit if not applicable.)
• Physical therapy: [Referral placed / Not indicated]
• Splint/orthotic: [Type and instructions if applicable] (Omit if not applicable.)

Signature

Electronically signed by: [Name, credentials] | [Date/time]

(Meta-instructions: Laterality must never be inferred. Medication names, doses, concentrations, and volumes must never be inferred. Consent status, time-out completion, and complications must always be explicitly documented. Explicitly state whether arthrocentesis/lavage was performed versus injection-only. For bilateral procedures, complete both Right TMJ and Left TMJ subsections; for unilateral, include only the treated side. If baseline or post-procedure measurements were not obtained, omit those specific lines rather than inserting placeholders. Omit the Findings section entirely if there are no notable findings.)