Sample Opnote – Fluoroscopic Guided Knee 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.]

[Written as if bilateral. Full procedure technique and overview here.]




Procedure: Intra-Articular Knee Joint Injection

Laterality: {{Bilateral}}

Pre-op diagnosis:

M25.561 – Pain in right knee

M25.562 – Pain in left knee

Post-op diagnosis: Same

Anesthesia: Local

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 knee 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.

Under fluoroscopic guidance, the intra-articular joint space was identified. 1% lidocaine was infiltrated subcutaneously on the anterolateral aspect of the {{left}} knee. At this point, a 25 gauge x 1.5 inch hypodermic needle was then placed from this point on the skin towards the intra-articular space. The needle was aspirated. It was negative for heme or paresthesias. 0.5 mL of Omnipaque contrast dye was injected and was noted to travel within the joint space. At this point, a 5 mL solution was injected consisting of 20 mg of triamcinolone and 4 mL of 0.5% Marcaine. 

The needle was then removed. The procedure was then repeated in the same fashion and with the same result on the contralateral side.

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.