Trigger Point Injection Procedure Note

Date/Time: [Procedure date and time]

Location: [Clinic or facility location]

Provider: [Provider name and credentials]

Patient: [Patient name and identifier]

Summary: [One-line laterality and region summary] (e.g., "Right cervical/upper trapezius—3 trigger points across 2 muscles"; do not infer)

Indication and Diagnosis

[Indication for trigger point injection] (1–3 sentences stating myofascial pain with identifiable trigger points, body region affected, functional limitation, and failure or partial response to conservative measures.)

Diagnosis: [Working diagnosis and ICD codes if provided]

Pre-Procedure Assessment

Relevant History: [Pain location, duration, severity pattern; prior conservative measures and response; specific functional limitations/ADL impacts] (For repeat sessions, include: date of last TPI, percent relief achieved with named scale, duration of relief, functional improvement with instrument name; state that pain has recurred with objective functional limitation and that patient continues participation in a conservative program—only when explicitly documented.)

Trigger Point Examination: [Muscles/regions examined and findings confirming trigger points] (Document taut band, focal hypersensitivity, referred pain pattern, local twitch response if elicited; note anatomic safety considerations such as proximity to thorax when relevant.)

Contraindications Screened: [Allergies, anticoagulation/bleeding risk, infection status, other relevant factors] (A single consolidated statement such as "No contraindications identified" is acceptable when explicitly stated.)

Informed Consent

[Consent obtained: written / verbal per policy] (Document discussion of indication and expected benefits, alternatives, and material risks: bleeding, infection, post-injection soreness, bruising, vasovagal syncope, nerve/vascular injury, and pneumothorax when injecting near thorax/upper back. Include steroid-specific risks if steroid used. State that questions were answered and patient agreed to proceed.)

Pre-Procedure Verification

[Time-out performed] (Confirm patient identity, procedure, site and laterality, allergies reviewed, correct medications verified with name and concentration. Document site marking status if used. Do not infer; if not documented, state "time-out not documented.")

Baseline Pain Score

Pre-procedure pain: [Pain score with named scale] (e.g., NRS 0–10 or VAS; include functional scale baseline if provided. If not documented, state "baseline pain score not documented.")

Procedure Details

Position: [Patient position]

Skin Preparation: [Antiseptic used and aseptic technique]

Localization: [Palpation-guided identification of trigger points]

(Include the following only if ultrasound guidance was used; omit entirely otherwise.)

Ultrasound Guidance: [Modality, structures visualized, needle visualization, and clinical rationale for imaging]

Needle: [Gauge and length]

Injectate: [Medication name, concentration, total volume prepared, total volume injected, calculated total dose in mg] (List each additive including steroids with concentration and dose. Do not infer.)

Muscles Treated:

• [Muscle name] ([L / R / bilateral]): [Number] sites, [Volume] mL

(Repeat for each muscle injected; associate all trigger points with specific muscle and laterality.)

Totals: [Total muscles] muscles, [Total sites] sites, [Total volume] mL [Injectate name and concentration] ([Total dose] mg) (Procedure coding is based on number of muscles treated, not number of injections.)

Technique: [Brief standardized narrative] (Needle insertion into trigger point, incremental injection with redirection within taut band, negative aspiration if performed, hemostasis with pressure, bandage applied. Keep concise.)

Post-Procedure Assessment

Tolerance: [Patient tolerance to procedure]

Complications: [None / Describe with management]

Post-procedure pain: [Pain score using same named scale as baseline]

Immediate relief: [Calculated percent improvement] (e.g., "Pre: 8/10, Post: 3/10, 62% immediate relief." If either score is missing, state that immediate relief could not be calculated.)

Aftercare Instructions

[Aftercare summary] (Expected transient soreness and bruising; encourage gentle ROM and stretching; avoid strenuous activity for specified period; analgesia options such as ice and OTC medications; warning signs requiring return: fever, increasing redness/swelling, neurologic symptoms, and for thoracic/upper back injections: chest pain or shortness of breath.)

Follow-Up Plan

[Plan] (Continuation of conservative program with any new instructions or referrals; timing of follow-up; criteria for repeat injection versus escalation to imaging, alternative diagnosis workup, or specialty referral.)

Signature

[Provider signature and credentials]