ortho1991
Guru
I hope someone can give guidance on this. Our physician is doing U/S guided injections here is a sample of dictation. My question is this enough documentation for an U/S injection.
The patient was brought into the procedure suite and positioned supine on the table with the affected side upwards and towards the side of the practitioner with the foot flat on the table to facilitate the ultrasound guided injection.
The fibula was identified at the lateral malleolus with ultrasound and followed inferiorly and distally with until identifying the calcaneocuboid joint space. This region is marked as the target for the injection with a plan to use an out of plane approach for the injection relative to the transducer.
Using a sterile kit and after applying drapes the area above the injection site was cleaned with a chlorhexidine prep stick. The ultrasound probe was then prepared using sterile technique. The target sight was then again visualized with the ultrasound probe. The skin and subcutaneous tissue along the trajectory for the procedure was anesthetized using a 25ga 1.5 inch needle with a lidocaine and sodium bicarbonate solution. Through the anesthetized skin and subcutaneous tissue a 1.5 inch 25ga needle was advanced under ultrasound guidance until reaching the targeted zone. A small amount of the injectate was instilled confirming proper positioning of the needle tip. Then after negative aspiration for blood, 1ml (40mg/ml) depomedrol with 1ml lidocaine with a total volume of 2ml was injected without resistance. As the needle was removed the needle tract was then flushed with the lidocaine solution. The alert and awake patient was then cleaned and a sterile dressing put into place.
The patient tolerated the procedure well and was then transferred to the waiting room in stable condition, without pain or paresthesias. The patient was observed in the waiting room for a brief period of time to assess pain as well as possible weakness before being released with appropriate discharge instructions.
Any help with this is appreciated, Thank you
The patient was brought into the procedure suite and positioned supine on the table with the affected side upwards and towards the side of the practitioner with the foot flat on the table to facilitate the ultrasound guided injection.
The fibula was identified at the lateral malleolus with ultrasound and followed inferiorly and distally with until identifying the calcaneocuboid joint space. This region is marked as the target for the injection with a plan to use an out of plane approach for the injection relative to the transducer.
Using a sterile kit and after applying drapes the area above the injection site was cleaned with a chlorhexidine prep stick. The ultrasound probe was then prepared using sterile technique. The target sight was then again visualized with the ultrasound probe. The skin and subcutaneous tissue along the trajectory for the procedure was anesthetized using a 25ga 1.5 inch needle with a lidocaine and sodium bicarbonate solution. Through the anesthetized skin and subcutaneous tissue a 1.5 inch 25ga needle was advanced under ultrasound guidance until reaching the targeted zone. A small amount of the injectate was instilled confirming proper positioning of the needle tip. Then after negative aspiration for blood, 1ml (40mg/ml) depomedrol with 1ml lidocaine with a total volume of 2ml was injected without resistance. As the needle was removed the needle tract was then flushed with the lidocaine solution. The alert and awake patient was then cleaned and a sterile dressing put into place.
The patient tolerated the procedure well and was then transferred to the waiting room in stable condition, without pain or paresthesias. The patient was observed in the waiting room for a brief period of time to assess pain as well as possible weakness before being released with appropriate discharge instructions.
Any help with this is appreciated, Thank you