Trigger Point/Tendon Sheath Injection Procedure Note

Date: [Date of procedure]

Time: [Time of procedure]

Location: [Clinic/procedure suite/room]

Patient Name: [Patient full name]

DOB: [Date of birth]

MRN: [Medical record number]

Performing Clinician: [Name, credentials]

Procedure Summary

[Brief procedure summary] (1–3 sentences. Include procedure type(s) [trigger point injection / tendon sheath injection / ligament or aponeurosis injection], laterality and anatomic region(s), guidance method [landmark/palpation / ultrasound-guided], and injectate summary with agents used.)

Indication

Primary diagnosis/indication: [Diagnosis/indication] (Do not infer diagnosis from procedure type; insert placeholder if not documented.)

Target symptoms and baseline severity: [Pain location(s), pain score 0–10, and/or functional limitation]

Prior treatments and response: [Physical therapy, medications, prior injections with dates and duration of benefit] (If repeat injection, state prior response and rationale for repeating now.)

Confirmatory exam findings: [Palpable taut band, focal tenderness, referred pain pattern, twitch response, positive provocative testing] (Include findings that support the anatomic targets selected.)

Pre-Procedure Assessment

• Allergies: [Allergies to local anesthetics, antiseptics, steroid components, latex, or NKDA] (Required before finalizing.)
• Anticoagulant/antiplatelet status: [Agent(s) and management plan, or none]
• Infection screening: [No active local or systemic infection / details if present]
• Baseline pain score: [0–10]
• Diabetes/steroid counseling: [Counseling regarding transient hyperglycemia documented] (Include only if steroid used in diabetic patient.)

Consent

[Consent statement] (Document that procedure, indication, risks, benefits, and alternatives were discussed; questions answered; patient agreed to proceed. Risks discussed: infection, bleeding, post-injection pain flare, allergic reaction, nerve/vascular injury. If steroid: skin atrophy/depigmentation, tendon weakening, hyperglycemia. If thoracic region: pneumothorax.)

Time-Out

Time-out performed immediately prior to procedure confirming patient identity, procedure, and site/laterality.

Procedure Details

Patient positioning: [Position]

Skin preparation: [Antiseptic agent and sterile technique]

Injection Targets

(Document each injection target separately.)

• Target: [Muscle name / tendon sheath / ligament / aponeurosis]

  Side: [right / left / bilateral]

  Identification method: [Palpation findings and/or ultrasound visualization]

  Technique: [Needle gauge and length], [approach], [technique details such as peppering/fanning if applicable]

  Injectate: [Agent name(s) and concentration(s)], [volume delivered to this target] (Required field.)

• Target: [Additional target]

  Side: [right / left / bilateral]

  Identification method: [Palpation findings and/or ultrasound visualization]

  Technique: [Needle gauge and length, approach, technique details]

  Injectate: [Agent(s), concentration(s), volume] (Required field.)

Total muscles injected: [Number] (Include for trigger point injections; coding depends on muscle count.)

Aspiration: [Performed / not performed] [Result if performed]

Hemostasis and dressing: [Method and dressing applied]

Complications: [None / description and management]

Patient tolerance: [Tolerated well / other]

Imaging Guidance

(Include only if imaging guidance was used; otherwise omit entire section.)

• Modality: [Ultrasound / fluoroscopy]
• Indication for guidance: [Clinical rationale]
• Needle visualization: [in-plane / out-of-plane] (For ultrasound.)
• Visualization confirmed: [Target structure, adjacent anatomy, needle tip position]
• Images archived: [Storage location or PACS ID per institutional policy]

Outcome

• Pre-procedure pain score: [0–10]
• Immediate post-procedure pain score: [0–10] [and/or percent relief]
• Functional assessment: [Change in ROM or provocative maneuver tolerance] (Include only if assessed.)
• Adverse events: [None / description and management]
• Disposition: [Tolerated procedure, discharged in stable condition / other]

Post-Procedure Plan

• Activity guidance: [Rest vs return to activity; duration of activity modification]
• Expected timeline: [Onset and peak effect if steroid used; possible transient pain flare]
• Red flags: [Fever, worsening pain, redness/swelling, drainage, new numbness/weakness] [Add chest pain/dyspnea if thoracic injection]
• Rehabilitation: [Physical therapy or home program plan]
• Follow-up: [Timeframe and clinic]