Wiki Documentation for Arthrocentesis and Injections

[amylynnwilson]

I am trying to find a break down of the required elements of documenting arthrocentesis/injection. Clarification on what I am looking for to ensure the injection is documented correctly. Something I can use to show providers what is missing. I have the gist, but having a detailed break down would be immensely helpful.

 

[Orthocoderpgu]

I don't know if you are going to find this documented and spelled out step by step. But every procedure like this should have documented how the area was sterilized, needle size, site of injection, stop point of the needle, medication used and how much, if a pull back was done was there blood or not? Document any abnormalities that occurred if any, how well the patient tolerated the injection. Depending on where the tip will be placed imaging will need to be used and described in the procedure. If the doc is just stating that they injected a joint without any further detail, that really is sub-par documentation. If anything happens during an injection or the patient has an adverse reaction, your doctor is going to want to have the procedure documented as specifically as possible, remember this is a legal note.

 

[amylynnwilson]

I don't know if you are going to find this documented and spelled out step by step. But every procedure like this should have documented how the area was sterilized, needle size, site of injection, stop point of the needle, medication used and how much, if a pull back was done was there blood or not? Document any abnormalities that occurred if any, how well the patient tolerated the injection. Depending on where the tip will be placed imaging will need to be used and described in the procedure. If the doc is just stating that they injected a joint without any further detail, that really is sub-par documentation. If anything happens during an injection or the patient has an adverse reaction, your doctor is going to want to have the procedure documented as specifically as possible, remember this is a legal note.

It is frustrating!! I appreciate your breakdown, it will help. I am working with Internal Med docs that do injections for pain management on occasion.