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  <title>Shoulder rotator cuff / biceps tendon PRP injection - ultrasound-guided</title>
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  <h1>Shoulder rotator cuff / biceps tendon PRP injection - ultrasound-guided</h1>
  <p><b>Form ID:</b> shoulder_tendon_prp_us &nbsp; <b>Type:</b> Procedure &nbsp; <b>Family:</b> PRP tendon/peritendon injection</p>
  <h2>Structured fields</h2>
  <table>
    <tr><th>Section</th><th>Field</th><th>Key</th><th>Default layer</th><th>Required</th><th>Quick text templates</th><th>History/exam sources</th></tr>
    <tr><td>Safety</td><td>Consent discussion</td><td><code>consent_phrase</code></td><td>Global Default</td><td>Required</td><td>Reviewed today and no patient-specific contraindication identified.; Patient-specific exception documented in the free-text field.</td><td></td></tr>
    <tr><td>Safety</td><td>Time-out and safety screen</td><td><code>timeout_phrase</code></td><td>Global Default</td><td>Required</td><td>Reviewed today and no patient-specific contraindication identified.; Patient-specific exception documented in the free-text field.</td><td></td></tr>
    <tr><td>Safety</td><td>Allergy / infection / anticoagulant screen result</td><td><code>allergy_infection_anticoagulant_screen</code></td><td>No Default</td><td>Required</td><td>No known relevant allergies; no active infection symptoms; anticoagulant/antiplatelet status reviewed.; Medication/allergy list reviewed; no contraindication identified today.; Anticoagulant/antiplatelet plan reviewed and documented before proceeding.; No fever, systemic infection symptoms, local skin infection, or open wound at the planned needle entry site reported today.; Diabetes/immunosuppression status reviewed; steroid risk and post-procedure monitoring discussed where applicable.; Pregnancy status, allergy history, anticoagulant plan, and medication list reviewed according to clinic protocol.; Patient denies contrast, latex, chlorhexidine/iodine, local anesthetic, or steroid allergy relevant to today&#x27;s plan.; Recent antibiotics, vaccination timing, infection symptoms, and wound concerns reviewed before proceeding.; No interval change in medical status that alters the planned procedure was identified today.; Patient-specific safety concern documented below and plan modified accordingly.; Reviewed today and no patient-specific contraindication identified.; Patient-specific exception documented in the free-text field.</td><td>red_flags_neuro_screen; red_flag_exam_findings; current_medications</td></tr>
    <tr><td>Indication</td><td>Diagnosis / indication</td><td><code>diagnosis</code></td><td>No Default</td><td>Required</td><td></td><td>condition_focus; pain_generator_impression; history_impression_plan</td></tr>
    <tr><td>Indication</td><td>Clinical indication and failed conservative therapy</td><td><code>clinical_indication</code></td><td>No Default</td><td>Required</td><td>Persistent function-limiting pain despite conservative management; procedure offered for diagnostic and/or therapeutic benefit.; Symptoms, examination, and available imaging are concordant with the planned target.; Prior treatment response and patient goals reviewed; patient wishes to proceed.; Procedure selected to clarify the pain generator and guide further treatment planning.; Pain distribution and provocative examination findings are consistent with the selected nerve/joint/tendon/enthesis target.; Repeat procedure considered because prior response was clinically meaningful and duration of benefit supports repeat treatment.; Regenerative/viscosupplementation option selected after discussion of expected onset, cost, alternatives, and uncertainty of response.; Ablation/PRF considered after diagnostic response and persistent recurrent pain in the same target distribution.; Neuromodulation/stimulation option considered for refractory neuropathic pain after conservative and injection-based options were reviewed.; Patient preference, functional goals, affordability, and medication risk profile were reviewed before final procedure selection.</td><td>presenting_complaint; pain_location_distribution; functional_limitations; prior_treatments; imaging_labs_tests; pain_generator_impression; procedural_target_assessment</td></tr>
    <tr><td>Indication</td><td>Laterality / side</td><td><code>side</code></td><td>No Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Setup</td><td>Patient position</td><td><code>patient_position</code></td><td>Per-Form Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Setup</td><td>Skin preparation</td><td><code>skin_prep</code></td><td>Global Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Setup</td><td>Sterile setup</td><td><code>sterile_setup</code></td><td>Global Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Setup</td><td>Monitoring</td><td><code>monitoring</code></td><td>Global Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Guidance</td><td>Guidance modality</td><td><code>guidance</code></td><td>Per-Form Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Guidance</td><td>Guidance documentation phrase</td><td><code>guidance_phrase</code></td><td>Global Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Guidance</td><td>Images saved / archive location</td><td><code>image_saved</code></td><td>No Default</td><td>Required</td><td>Representative images saved to clinic imaging archive.; Image storage not technically feasible; guidance findings documented in note.; Fluoroscopic images stored according to clinic workflow.; Pre-injection target image and post-injection spread image saved.; Needle tip/cannula position image saved before treatment delivery.; Ultrasound image demonstrating target anatomy, adjacent vessels, and final needle tip position saved.; No image saved because procedure was landmark-based; anatomic landmarks and endpoint are documented.; Device/programming procedure only; image archive not applicable.</td><td>imaging_labs_tests; procedural_target_assessment</td></tr>
    <tr><td>Outcome</td><td>Immediate response / pain score change</td><td><code>immediate_response</code></td><td>No Default</td><td>Required</td><td>Tolerated well; immediate response to be assessed over the expected therapeutic window.; No immediate complication; post-procedure pain/function response reviewed before discharge.; Immediate pain score and functional response documented after reassessment.; Patient remained neurologically at baseline after the procedure.; Expected temporary sensory/motor change reviewed before discharge.; Initial diagnostic response was reviewed, recognizing that anesthetic onset and steroid/regenerative effect differ.; Patient ambulated/transitioned from procedure position without new concerning symptoms.; Device stimulation/programming response was reviewed with the patient before discharge.; No vasovagal symptoms, allergic symptoms, or new neurologic deficit observed during immediate recovery.; No immediate complication observed.; Response will be reassessed after the expected onset window.</td><td>history_impression_plan; exam_plan</td></tr>
    <tr><td>Outcome</td><td>Complications / adverse event</td><td><code>complications</code></td><td>No Default</td><td>Required</td><td>None.; No immediate adverse event observed.; Transient expected procedural discomfort only.; Transient vasovagal symptoms occurred and resolved with supportive care.; Minor superficial bleeding/oozing controlled with local pressure.; Transient paresthesia occurred during needle placement and resolved after repositioning.; Procedure modified or stopped because of patient discomfort/safety concern, as documented.; No allergic reaction, infection concern, new neurologic deficit, or hematoma observed immediately.; No immediate complication observed.; Response will be reassessed after the expected onset window.</td><td></td></tr>
    <tr><td>Disposition</td><td>Post-procedure instructions</td><td><code>post_procedure_instructions</code></td><td>Global Default</td><td>Required</td><td>Post-procedure instructions and warning signs reviewed; patient advised to seek urgent care for concerning symptoms.; Activity modification, expected soreness, medication precautions, and red flags reviewed.; Written and verbal aftercare instructions provided according to clinic protocol.; Avoid strenuous activity for the remainder of the day; resume usual activity gradually as tolerated unless otherwise instructed.; Avoid soaking/submerging the injection site for 24 hours or according to clinic protocol.; Monitor for fever, progressive redness/swelling, severe escalating pain, new weakness/numbness, bowel/bladder changes, or allergic symptoms.; For steroid procedures, delayed onset, transient flare, and glucose effects were reviewed where applicable.; For PRP/prolotherapy, post-procedure soreness and medication restrictions were reviewed according to clinic protocol.; For ablation/PRF, expected neuritis/soreness timeline and delayed benefit window were reviewed.; For stimulation/device procedures, dressing care, activity restrictions, device contact instructions, and red flags were reviewed.; Aftercare, red flags, and follow-up plan reviewed with patient.</td><td></td></tr>
    <tr><td>Disposition</td><td>Follow-up plan</td><td><code>follow_up_plan</code></td><td>Global Default</td><td>Required</td><td>Follow-up arranged according to response and treatment plan; patient advised to track pain, function, and adverse effects.; Reassess pain score, functional change, medication use, and adverse effects at follow-up.; Patient will contact clinic earlier for concerning symptoms or inadequate response.; Pain diary requested to capture percent relief, duration of benefit, activity tolerance, and medication change.; If diagnostic block is positive, consider confirmatory block and/or ablation according to clinic protocol.; If steroid response is beneficial but temporary, repeat interval should respect safety limits and clinical necessity.; If inadequate response, reassess diagnosis, target selection, imaging, and alternative procedure options.; For regenerative or viscosupplementation treatment, reassess over the expected delayed response window.; For stimulation/neuromodulation, review coverage, functional response, device tolerance, and programming needs.; Aftercare, red flags, and follow-up plan reviewed with patient.</td><td>history_impression_plan; exam_plan; patient_preferences_affordability</td></tr>
    <tr><td>Technique</td><td>Transducer / probe</td><td><code>transducer</code></td><td>Per-Form Default</td><td>Optional</td><td></td><td></td></tr>
    <tr><td>Technique</td><td>Needle approach</td><td><code>approach</code></td><td>Per-Form Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Technique</td><td>Needle target</td><td><code>target</code></td><td>Per-Form Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Technique</td><td>Needle type / gauge / length</td><td><code>needle</code></td><td>Per-Form Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Technique</td><td>Needle visualization / path</td><td><code>needle_visualization</code></td><td>No Default</td><td>Required</td><td>Needle advanced under continuous in-plane visualization with tip position confirmed before injection.; Needle/cannula position confirmed with image guidance before treatment.; Needle path adjusted to avoid visible vessels and surrounding sensitive structures.; Needle advanced incrementally with frequent tip confirmation before each injection.; Out-of-plane approach used; needle tip location confirmed by tissue movement, hydrodissection, and/or target response.; RF cannula position confirmed at the intended target before sensory/motor testing and treatment.; Lead/introducer position confirmed according to device protocol before stimulation testing/programming.; Landmark endpoint reached without paresthesia, vascular puncture, or concerning resistance.; Needle repositioned until injectate spread/target endpoint was acceptable.</td><td>procedural_target_assessment; condition_specific_exam</td></tr>
    <tr><td>Technique</td><td>Aspiration result</td><td><code>aspiration_result</code></td><td>No Default</td><td>Required</td><td>Negative; No blood or fluid aspirated before injection.; Not applicable.; Negative aspiration before each aliquot.; Negative aspiration and no paresthesia before injection.; Sensory/motor testing was acceptable before RF treatment.; Stimulation response/coverage was acceptable before lead finalization.; Aspiration was not applicable because no injectate was delivered.</td><td></td></tr>
    <tr><td>Technique</td><td>Injection character / resistance / spread</td><td><code>injection_character</code></td><td>No Default</td><td>Required</td><td>Injectate spread was visualized in the intended tissue plane/target region without high resistance.; Injection proceeded smoothly without paresthesia, severe pain, or concerning resistance.; Injectate distribution was acceptable for the planned target.; Hydrodissection opened the intended plane and confirmed extraneural/peritendinous spread.; Perineural spread was seen without nerve swelling or intraneural injection appearance.; Intra-articular or pericapsular spread was acceptable for the intended target.; Fascial plane spread tracked along the expected anatomic plane.; No vascular uptake, unexpected pain, or concerning resistance occurred during injection.; Treatment endpoint was achieved; no injectate was required beyond local anesthetic as documented.</td><td></td></tr>
    <tr><td>Injectate/Product</td><td>PRP product/preparation</td><td><code>injectate_product</code></td><td>Per-Form Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Injectate/Product</td><td>PRP volume injected</td><td><code>dose_volume</code></td><td>Per-Form Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Injectate/Product</td><td>Lot number and expiry</td><td><code>lot_expiry</code></td><td>No Default</td><td>Required</td><td>Lot/expiry recorded in clinic medication administration workflow.; Product identifiers, lot, and expiry reviewed and documented where applicable.; Autologous product prepared and documented according to clinic PRP workflow.; Device identifiers and programming details documented according to device workflow.; Not applicable for this encounter.</td><td></td></tr>
    <tr><td>Injectate/Product</td><td>Diluent / local anesthetic component</td><td><code>diluent_anesthetic</code></td><td>Per-Form Default</td><td>Optional</td><td></td><td></td></tr>
    <tr><td>Injectate/Product</td><td>Total injectate volume</td><td><code>total_volume</code></td><td>Per-Form Default</td><td>Required</td><td>Total volume delivered as documented in medication fields.; Low-volume diagnostic injectate delivered by target.; Total volume divided among documented targets.; No therapeutic injectate delivered beyond local anesthetic for needle/cannula placement.; Device/RF settings documented; total injectate volume not applicable except local anesthetic.</td><td></td></tr>
    <tr><td>PRP Preparation</td><td>PRP system / kit</td><td><code>prp_system</code></td><td>Per-Form Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>PRP Preparation</td><td>Blood draw volume</td><td><code>blood_draw_volume</code></td><td>No Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>PRP Preparation</td><td>Spin protocol / processing details</td><td><code>spin_protocol</code></td><td>Per-Form Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Technique</td><td>Fenestration/peppering pattern if performed</td><td><code>fenestration_pattern</code></td><td>No Default</td><td>Optional</td><td></td><td></td></tr>
    <tr><td>Recommended next procedure</td><td>Recommended next procedure date</td><td><code>next_procedure_date</code></td><td>No Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Recommended next procedure</td><td>Medication choice</td><td><code>next_procedure_medication_choice</code></td><td>Per-Form Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Recommended next procedure</td><td>Dose</td><td><code>next_procedure_dose</code></td><td>Per-Form Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Recommended next procedure</td><td>Technique</td><td><code>next_procedure_technique</code></td><td>Per-Form Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Recommended next procedure</td><td>Patient position</td><td><code>next_procedure_patient_position</code></td><td>Per-Form Default</td><td>Required</td><td></td><td></td></tr>
    <tr><td>Recommended next procedure</td><td>Premedication</td><td><code>next_procedure_premedication</code></td><td>Per-Form Default</td><td>Optional</td><td></td><td></td></tr>
    <tr><td>Recommended next procedure</td><td>Pre-procedure comments</td><td><code>next_procedure_pre_procedure_comments</code></td><td>Per-Form Default</td><td>Optional</td><td>Reassess indication, response to current procedure, contraindications, patient preference, and affordability before proceeding.; Repeat only if clinically indicated after response and safety review.; Confirm medication/product availability, consent, and interval safety before booking.; For steroid repeat, confirm minimum interval and cumulative steroid exposure are clinically appropriate.; For ablation repeat, confirm recurrence pattern and prior duration of benefit before repeating.; For stimulation follow-up, confirm device status, wound status, coverage, charging/use pattern, and programming needs.; If response is inadequate, reassess pain generator before repeating the same target.</td><td>history_impression_plan; exam_plan; patient_preferences_affordability</td></tr>
    <tr><td>Recommended next procedure</td><td>Intra-procedure comments</td><td><code>next_procedure_intra_procedure_comments</code></td><td>Per-Form Default</td><td>Optional</td><td>Use same technique unless anatomy, response, or safety considerations require modification.; Adjust target/approach based on updated exam, imaging, and response to previous procedure.; Document any change in guidance, target, needle/cannula, or device settings.; Use ultrasound, fluoroscopy, landmark, or device workflow selected at the time of procedure.; Consider lower volume, alternate plane, alternate target, or staged targets if prior spread/response was suboptimal.; For RF/PRF, repeat sensory/motor testing and document settings rather than carrying forward prior settings blindly.; For regenerative treatment, document product preparation/yield and target-specific fenestration or injection pattern.</td><td></td></tr>
    <tr><td>Recommended next procedure</td><td>Post-procedure comments</td><td><code>next_procedure_post_procedure_comments</code></td><td>Per-Form Default</td><td>Optional</td><td>Reassess response, adverse effects, function, and need for further treatment after the next procedure.; Track pain diary, functional goals, and medication change after the next procedure.; Review whether further repeat procedure remains appropriate before additional treatment.; Review delayed onset window appropriate to steroid, HA, PRP, prolotherapy, ablation, or stimulation.; Document percent relief, duration, functional gain, adverse effects, and patient preference before further repeat treatment.; For device treatment, review coverage map, programming changes, wound/device concerns, and next programming interval.</td><td></td></tr>
  </table>
  <h2>Narrative template</h2>
  <div class="note">Shoulder rotator cuff / biceps tendon PRP injection - ultrasound-guided<br><br>Indication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}<br><br>Consent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}<br><br>Setup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}<br><br>Guidance: {{guidance_phrase}} Images: {{image_saved}}<br><br>Technique: Autologous PRP was prepared. Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}<br><br>Product/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.<br><br>PRP preparation: System: {{prp_system}}. Blood draw volume: {{blood_draw_volume}}. Spin protocol: {{spin_protocol}}. Fenestration: {{fenestration_pattern}}.<br><br>Outcome: Immediate response: {{immediate_response}} Complications: {{complications}}<br><br>Disposition: {{post_procedure_instructions}} {{follow_up_plan}}<br><br>Recommended next procedure: Date: {{next_procedure_date}}. Medication choice: {{next_procedure_medication_choice}}. Dose: {{next_procedure_dose}}. Technique: {{next_procedure_technique}}. Patient position: {{next_procedure_patient_position}}. Premedication: {{next_procedure_premedication}}. Pre-procedure comments: {{next_procedure_pre_procedure_comments}}. Intra-procedure comments: {{next_procedure_intra_procedure_comments}}. Post-procedure comments: {{next_procedure_post_procedure_comments}}.</div>
  <p>Physician review required before signing in the EMR. Verify actual medications, doses, lot/expiry, devices, image documentation, response, complications, and follow-up.</p>
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