Post Procedure Note

Bedside Time Out final verification process was completed just before procedure.

Patient Identity Actively Confirmed by two identifiers:

(Full Name, Full SSN,Date of Birth) Yes -

Procedure site and side actively confirmed with patient:

Yes -

Procedure type actively confirmed with the patient:

Yes -

Procedure:

Arthrocentesis

The area was cleansed with tinted ChloraPrep and a topical anesthetic sprayed

to area.

Using aseptic technique, the patient's {FLD:BDV INJECTION RIGHT/LEFT} subacromial space was then injected via posterolateral approach with a sterile 25 gauge 1 1/2" needle

containing 40 mg depomedrol + 1% lidocaine (2cc).

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Using aseptic technique, the patient's {FLD:BDV INJECTION RIGHT/LEFT} knee joint space was then injected via anterolateral approach with knee flexed to 90 degrees with a

sterile 25 gauge 1 1/2" needle containing 40 mg depomedrol + 1% lidocaine (2cc).

Lot number: w25524 Exp date: 4/2019

Patient tolerated procedure well with estimated blood loss: none

Veteran noted - {FLD:YES - NO}- significant improvement shortly after injection

Pain Level: {FLD:0-10 BOX}

The patient was instructed to ice the joint tonight and can take

Tylenol as needed for comfort

If with fever, increased pain with redness, swelling, or streaking,

please report to the nearest Emergency Dept for further evaluation.

Post-procedure handout given to patient.