Ultrasound-Guided Joint Aspiration/Injection Procedure Note

Date: [Date of procedure]

Time: [Start time – End time]

Location: [Clinic/Procedure room/Bedside location]

Proceduralist: [Name, credentials]

Target Site: [Joint or bursa name – specific recess if applicable] ([Left / Right])

Procedure Type: [aspiration / injection / aspiration and injection]

Procedure Title

Ultrasound-Guided [Joint/Bursa] [Arthrocentesis / Injection / Arthrocentesis and Injection] ([Left / Right])

Indication

[Presenting problem or working diagnosis and clinical purpose] (In 1–3 sentences, state the clinical indication and purpose: diagnostic aspiration, therapeutic aspiration, and/or therapeutic injection. Explicitly state why ultrasound guidance was used, such as small effusion, obesity, altered anatomy, nearby neurovascular structures, or prior failed landmark attempt.)

Consent

[Consent type and details] (Specify written or verbal consent and who provided it. Document that risks were discussed—infection, bleeding, pain, allergic reaction, vasovagal reaction, post-injection flare, and steroid-specific risks if applicable—alternatives were reviewed, questions answered, and patient agreed. If consent was not obtainable, explicitly state the reason.)

Time-Out

• Patient identity confirmed with two identifiers
• Correct procedure confirmed
• Correct site and laterality confirmed: [Left / Right] [Joint/Bursa]
• Allergies reviewed: [Allergies or NKDA]
• Anticoagulation/bleeding risk reviewed (Include only if relevant.)
• Required equipment and medications confirmed available

Pre-Procedure Assessment

• Targeted exam findings: [Findings relevant to procedure] (e.g., effusion, warmth, range of motion, tenderness; only include items assessed)
• Contraindications considered: [None identified / Specific considerations] (e.g., overlying cellulitis, coagulopathy)
• Baseline pain score: [Score] (Include only if obtained.)

Equipment & Medications

• Antisepsis & Sterile Technique: [Skin antiseptic agent], [sterile gloves / sterile drape / probe cover / sterile gel]
• Ultrasound: [Probe type and frequency]
• Needle: [Gauge], [Length]
• Local anesthetic (skin/subcutaneous): [Agent], [Concentration], [Volume in mL]
• Intra-articular injectate: (Include only if injection performed.)
  • [Corticosteroid name and dose in mg] (Include only if steroid used.)
  • [Anesthetic agent and volume in mL]
  • Total volume injected: [mL]

Ultrasound Guidance

• Pre-procedure survey: [Patient positioning], [Planned sonographic approach], [Key structures visualized: effusion, synovium, tendons, neurovascular structures], [Doppler assessment: performed / not performed] (Describe findings that informed the approach.)
• Needle guidance: [In-plane / Out-of-plane] approach with real-time ultrasound guidance. Needle tip visualization: [consistent throughout / intermittent]. (If intermittent, document how final position was confirmed: aspiration of fluid, sonographic spread of injectate, or other method.)
• Permanent record: [Images captured, labeled with site and laterality, and stored in permanent medical record / Ultrasound used for dynamic guidance only; no images archived] (This statement is required—must explicitly document whether images were or were not saved.)

Procedure Details

• Patient position: [Positioning details]
• Skin entry site: [Entry site description]
• Local anesthesia: [Infiltration technique and depth]
• Needle advancement: [Ultrasound-guided trajectory to target]
• Aspiration: [Volume aspirated in mL], [Fluid appearance: clear / cloudy / bloody / purulent / xanthochromic], [Complete / Partial aspiration] (Include only if aspiration performed. For dry tap: document ultrasound findings, number of attempts, and rationale for stopping.)
• Injection: [Confirmation of intra-articular placement: ease of injection / sonographic injectate spread / other] (Include only if injection performed.)
• Same needle tract used for aspiration and injection: [yes / no / N/A]
• Dressing: [Dressing type applied]

Specimen Handling

(Include this section only if aspiration performed and specimens sent. Omit entirely if no aspiration or no specimens sent.)

• Tests ordered: [Cell count with differential / Gram stain / Culture / Crystal analysis / Other]
• Labeling: Specimens labeled at bedside with patient identifiers, site, laterality, and date/time

Outcome

Technical success: [yes / partial / no]. Patient tolerated procedure [well / with difficulty]. [Immediate symptom change if noted]

Complications

[None / Description of complication and actions taken] (Do not omit; explicitly state "None" if no complications occurred.)

Post-Procedure

[Patient condition on completion]. [Follow-up plan and who will review lab results]. [Scheduled follow-up if applicable]

Signature

[Proceduralist signature and credentials]

(If trainee performed procedure, include supervising physician attestation with level of supervision.)