Sample Opnote – Fluoroscopic Guided Hip Joint Injection

[This is a sample procedure note and may not match the corresponding guide exactly: As with all procedures there will be slight variations based on body habitus, technique preference, laterality, etc. Treat this as a starting point for a template. The brackets {{ }} are used in the body as placeholders for dynamic variables.]




Procedure: Intraarticular Hip Joint Injection

Laterality: Right

Pre-op diagnosis:

M25.551 – Pain in right hip

Post-op diagnosis: Same

Anesthesia: MAC

Pre-Procedure Review: The initial consultation report has been reviewed and there are no changes with regard to the patient’s medical, social history and review of systems. The patient states that the symptoms are stable and unchanged since the last visit. My findings on physical examination today are grossly consistent with those documented on the previous follow-up note, at which time today’s procedure was scheduled. I will proceed today with the scheduled procedure and see the patient back for follow-up. The patient states understanding of the plan, and is in agreement.

Indication:To mitigate inflammation present within the hip joint in order to decrease or eliminate pain arising from osteoarthritis.

Description:The history and physical examination were reviewed to ensure accuracy, and the details of the procedure were reviewed with the patient who understands all of the risks and benefits involved. All questions were answered, and the patient is aware of all alternative therapeutic options. An informed consent was obtained, and the patient was directed to the procedure room. A “time-out” with two active identifiers of the patient, the procedure, and the site was performed. The patient was positioned supine on the fluoroscopy table. All pressure points were padded and checked routinely. The patient’s level of consciousness was monitored throughout. The treated areas were widely sterilized using a Betadine solution and were draped in a sterile manner.

Lidocaine was used to make a skin wheal directly lateral to the femoral neck on the right side. The subcutaneous tissue was then anesthetized and a 3-1/2-inch 22-gauge Quincke needle with a 30-degree bend at the tip was advanced in a target fashion using fluoroscopic guidance in the AP view. The needle was advanced until the tip made contact with the neck of the femur, on the anterior side. The tip was then withdrawn a few millimeters. An aspiration test was negative for blood or paresthesias. Thereafter, 0.5 mL of contrast was slowly injected (without incident) and fluoroscopic imaging revealed medial spread of the dye along the joint space of the hip. 40 mg of triamcinolone diluted with 4 mL of 0.5% Marcaine to a total volume of 5 mL was then slowly injected with ease and without incident. The needle was then withdrawn.

Total fluoroscopy exposure was {{}} minutes ({{}}mGy).

The patient tolerated the procedure well, was taken to the recovery area, and was discharged once criteria were met.

Anesthesia Addendum: {{standard anesthesia addendum if applicable}}