<!doctype html>
<html lang="en">
<head>
  <meta charset="utf-8">
  <meta name="viewport" content="width=device-width, initial-scale=1">
  <title>Epione EMR Template System v0.7</title>
  <style>
    :root {
      --bg: #f6f7f9;
      --panel: #ffffff;
      --ink: #172026;
      --muted: #66727c;
      --line: #d9dee3;
      --line-strong: #bbc4cc;
      --accent: #0f766e;
      --accent-2: #174ea6;
      --danger: #b42318;
      --warn: #b54708;
      --ok: #027a48;
      --field: #fbfcfd;
      --shadow: 0 10px 24px rgba(23, 32, 38, .08);
      --radius: 8px;
    }
    * { box-sizing: border-box; }
    body { margin: 0; background: var(--bg); color: var(--ink); font: 14px/1.45 -apple-system, BlinkMacSystemFont, "Segoe UI", sans-serif; }
    button, input, select, textarea { font: inherit; }
    button { cursor: pointer; }
    .app { min-height: 100vh; display: grid; grid-template-rows: auto 1fr; }
    .topbar { height: 56px; display: flex; align-items: center; justify-content: space-between; gap: 16px; padding: 0 18px; background: var(--panel); border-bottom: 1px solid var(--line); }
    .brand { display: flex; align-items: baseline; gap: 10px; min-width: 240px; }
    .brand h1 { margin: 0; font-size: 16px; font-weight: 720; letter-spacing: 0; }
    .brand span { color: var(--muted); font-size: 12px; }
    .top-actions { display: flex; align-items: center; gap: 8px; }
    .status { color: var(--muted); font-size: 12px; }
    .shell { min-height: 0; display: grid; grid-template-columns: 330px minmax(520px, 1fr) 390px; }
    .sidebar, .preview { min-height: 0; overflow: auto; background: var(--panel); }
    .sidebar { border-right: 1px solid var(--line); }
    .preview { border-left: 1px solid var(--line); }
    .main { min-height: 0; overflow: auto; padding: 18px; }
    .section { padding: 14px; border-bottom: 1px solid var(--line); }
    .section-title { margin: 0 0 10px; color: var(--muted); font-size: 11px; font-weight: 760; text-transform: uppercase; letter-spacing: .04em; }
    .search { width: 100%; height: 36px; padding: 0 10px; border: 1px solid var(--line); border-radius: 7px; background: var(--field); }
    .segmented { display: grid; grid-template-columns: repeat(4, 1fr); gap: 4px; padding: 4px; background: #edf1f4; border-radius: 8px; }
    .segmented button { border: 0; border-radius: 6px; padding: 7px 8px; color: var(--muted); background: transparent; font-size: 12px; }
    .segmented button.active { color: var(--ink); background: var(--panel); box-shadow: 0 1px 4px rgba(23,32,38,.10); }
    .condition-list, .form-list { display: grid; gap: 6px; }
    .guide { display: grid; gap: 10px; }
    .guide-step { border: 1px solid var(--line); border-radius: 7px; background: #fbfcfd; overflow: hidden; }
    .guide-question { width: 100%; display: flex; align-items: center; justify-content: space-between; gap: 8px; border: 0; border-bottom: 1px solid var(--line); background: #f7f9fa; padding: 8px 10px; text-align: left; color: var(--ink); font-weight: 700; }
    .guide-question span { color: var(--muted); font-weight: 600; font-size: 12px; }
    .choice-grid { display: grid; gap: 5px; padding: 8px; }
    .choice-button { text-align: left; border: 1px solid var(--line); border-radius: 6px; background: #fff; padding: 7px 8px; color: var(--ink); font-size: 12px; }
    .choice-button:hover { border-color: #9cc7c1; background: #f2fbf9; }
    .choice-button.active { border-color: var(--accent); background: #e7f4f2; color: #0b4f49; font-weight: 700; }
    .choice-button .count { color: var(--muted); float: right; font-weight: 600; }
    .row-button { text-align: left; border: 1px solid transparent; border-radius: 7px; background: transparent; padding: 9px; color: var(--ink); }
    .row-button:hover { background: #f1f5f6; }
    .row-button.active { background: #e7f4f2; border-color: #a9d8d2; }
    .row-title { font-weight: 650; font-size: 13px; }
    .row-meta { color: var(--muted); font-size: 12px; margin-top: 2px; }
    .toolbar { display: flex; align-items: center; justify-content: space-between; gap: 12px; margin-bottom: 14px; }
    .title-block h2 { margin: 0; font-size: 20px; line-height: 1.2; }
    .title-block p { margin: 5px 0 0; color: var(--muted); }
    .btn { height: 34px; border: 1px solid var(--line-strong); border-radius: 7px; padding: 0 11px; background: var(--panel); color: var(--ink); }
    .btn.primary { border-color: var(--accent); background: var(--accent); color: white; }
    .btn.danger { border-color: #f1b4ad; color: var(--danger); }
    .btn:disabled { opacity: .55; cursor: not-allowed; }
    .metrics { display: grid; grid-template-columns: repeat(4, minmax(0, 1fr)); gap: 10px; margin-bottom: 14px; }
    .metric { background: var(--panel); border: 1px solid var(--line); border-radius: var(--radius); padding: 10px; }
    .metric strong { display: block; font-size: 18px; }
    .metric span { color: var(--muted); font-size: 12px; }
    .panel { background: var(--panel); border: 1px solid var(--line); border-radius: var(--radius); box-shadow: var(--shadow); overflow: hidden; }
    .panel-head { display: flex; align-items: center; justify-content: space-between; gap: 10px; padding: 12px 14px; border-bottom: 1px solid var(--line); }
    .panel-head h3 { margin: 0; font-size: 14px; }
    .fields { display: grid; gap: 14px; padding: 14px; }
    .field-group { display: grid; gap: 10px; }
    .group-title { color: var(--muted); font-size: 12px; font-weight: 750; text-transform: uppercase; letter-spacing: .04em; }
    .field { display: grid; grid-template-columns: 220px minmax(260px, 1fr); gap: 12px; align-items: start; padding: 10px; border: 1px solid var(--line); border-radius: 7px; background: #fff; }
    .field label { font-weight: 650; }
    .field .help { margin-top: 4px; color: var(--muted); font-size: 12px; }
    .field input, .field textarea, .field select { width: 100%; border: 1px solid var(--line-strong); border-radius: 7px; background: var(--field); padding: 8px 9px; min-height: 36px; }
    .field textarea { min-height: 82px; resize: vertical; }
    .field-controls { display: grid; gap: 7px; }
    .quick-choice-list { display: flex; flex-wrap: wrap; gap: 6px; max-height: 108px; overflow: auto; padding: 7px; border: 1px solid #c9e4e0; border-radius: 7px; background: #f2fbf9; }
    .quick-choice { border: 1px solid #a9d8d2; border-radius: 999px; background: #fff; color: #0b4f49; padding: 5px 8px; font-size: 11px; line-height: 1.25; text-align: left; max-width: 100%; }
    .quick-choice:hover, .quick-choice:focus { border-color: var(--accent); background: #e7f4f2; outline: none; }
    .quick-choice.compact { max-width: 320px; overflow: hidden; text-overflow: ellipsis; white-space: nowrap; }
    .assist-panel { margin-bottom: 14px; }
    .context-grid { display: grid; grid-template-columns: repeat(2, minmax(0, 1fr)); gap: 10px; padding: 12px 14px; }
    .context-item { border: 1px solid var(--line); border-radius: 7px; padding: 9px; background: #fbfcfd; }
    .context-item strong { display: block; font-size: 12px; margin-bottom: 4px; }
    .context-item span { color: var(--muted); font-size: 12px; }
    .context-actions { display: flex; flex-wrap: wrap; gap: 8px; padding: 0 14px 14px; }
    .favorite-panel { margin-bottom: 14px; }
    .favorite-grid { display: grid; grid-template-columns: minmax(0, 1fr) auto auto auto; gap: 8px; padding: 12px 14px; align-items: center; }
    .favorite-grid input, .favorite-grid select { min-height: 34px; border: 1px solid var(--line-strong); border-radius: 7px; background: var(--field); padding: 7px 8px; }
    .field-meta { display: flex; flex-wrap: wrap; gap: 6px; margin-top: 7px; }
    .tag { display: inline-flex; align-items: center; min-height: 21px; border: 1px solid var(--line); border-radius: 999px; padding: 2px 7px; color: var(--muted); background: #f7f9fa; font-size: 11px; }
    .tag.required { border-color: #f3b7b2; color: var(--danger); background: #fff3f1; }
    .tag.default { border-color: #abd5f5; color: var(--accent-2); background: #edf7ff; }
    .tag.manual { border-color: #f4c790; color: var(--warn); background: #fff7ed; }
    .preview-inner { padding: 14px; }
    .note { white-space: pre-wrap; min-height: 340px; padding: 14px; border: 1px solid var(--line); border-radius: var(--radius); background: #fbfcfd; font-family: ui-monospace, SFMono-Regular, Menlo, Consolas, monospace; font-size: 12px; line-height: 1.55; }
    .missing { display: grid; gap: 6px; margin: 0 0 12px; }
    .missing-item { border-left: 3px solid var(--danger); background: #fff3f1; padding: 7px 8px; border-radius: 5px; color: #7a271a; font-size: 12px; }
    .product-box { margin-top: 14px; border: 1px solid var(--line); border-radius: var(--radius); overflow: hidden; }
    .product-row { display: grid; grid-template-columns: 1fr auto; gap: 8px; padding: 9px; border-top: 1px solid var(--line); }
    .product-row:first-child { border-top: 0; }
    .product-row span { color: var(--muted); font-size: 12px; }
    .review-box { margin-top: 14px; border: 1px solid var(--line); border-radius: var(--radius); background: var(--panel); overflow: hidden; }
    .review-body { display: grid; gap: 9px; padding: 11px; }
    .review-item { display: grid; grid-template-columns: 18px 1fr; gap: 8px; align-items: start; color: var(--ink); font-size: 12px; }
    .review-item input { margin-top: 2px; }
    .review-grid { display: grid; grid-template-columns: 1fr 118px; gap: 8px; }
    .review-grid input, .review-box textarea { width: 100%; border: 1px solid var(--line-strong); border-radius: 7px; background: var(--field); padding: 7px 8px; font-size: 12px; }
    .review-box textarea { min-height: 62px; resize: vertical; }
    .review-actions { display: flex; flex-wrap: wrap; gap: 8px; }
    .review-status { font-size: 12px; font-weight: 700; }
    .review-status.ready { color: var(--ok); }
    .review-status.blocked { color: var(--danger); }
    .pill-no { color: var(--danger); font-weight: 700; }
    .empty { padding: 18px; color: var(--muted); text-align: center; }
    @media (max-width: 1180px) { .shell { grid-template-columns: 300px 1fr; } .preview { grid-column: 1 / -1; border-left: 0; border-top: 1px solid var(--line); } }
    @media (max-width: 760px) { .topbar { height: auto; padding: 12px; align-items: flex-start; flex-direction: column; } .shell { grid-template-columns: 1fr; } .sidebar, .preview { max-height: none; border: 0; border-bottom: 1px solid var(--line); } .field { grid-template-columns: 1fr; } .metrics { grid-template-columns: repeat(2, 1fr); } .toolbar { align-items: flex-start; flex-direction: column; } }
  </style>
</head>
<body>
  <div class="app">
    <header class="topbar">
      <div class="brand"><h1>Epione EMR Templates</h1><span>v0.7 clinical documentation workspace</span></div>
      <div class="top-actions">
        <span class="status" id="saveStatus">No patient data leaves this browser.</span>
        <button class="btn" id="exportTxt">Export TXT</button>
        <button class="btn primary" id="copyNote">Copy Note</button>
      </div>
    </header>
    <div class="shell">
      <aside class="sidebar">
        <div class="section">
          <p class="section-title">Find Template</p>
          <input class="search" id="search" placeholder="Search conditions, procedures, fields">
        </div>
        <div class="section">
          <p class="section-title">Template Type</p>
          <div class="segmented" id="typeTabs">
            <button data-type="all" class="active">All</button>
            <button data-type="History">History</button>
            <button data-type="Physical Exam">Exam</button>
            <button data-type="Procedure">Procedure</button>
          </div>
        </div>
        <div class="section">
          <p class="section-title">Guided Procedure Path</p>
          <div class="guide" id="guidedPath"></div>
        </div>
        <div class="section form-picker">
          <p class="section-title">Forms</p>
          <div class="form-list" id="formList"></div>
        </div>
        <div class="section">
          <p class="section-title">Conditions</p>
          <div class="condition-list" id="conditions"></div>
        </div>
      </aside>
      <main class="main">
        <div class="toolbar">
          <div class="title-block">
            <h2 id="formTitle">Select a form</h2>
            <p id="formMeta">Choose a condition or search for a procedure.</p>
          </div>
          <div class="top-actions">
            <button class="btn danger" id="clearInputs">Clear Inputs</button>
            <button class="btn" id="fillDemo">Fill Demo</button>
          </div>
        </div>
        <div class="metrics">
          <div class="metric"><strong id="metricForms">0</strong><span>Forms</span></div>
          <div class="metric"><strong id="metricRequired">0</strong><span>Required Fields</span></div>
          <div class="metric"><strong id="metricMissing">0</strong><span>Missing Manual Fields</span></div>
          <div class="metric"><strong id="metricDefaults">0</strong><span>Resolved Defaults</span></div>
        </div>
        <section class="panel">
          <div class="panel-head"><h3>History / Physical Exam Assist</h3><span class="status" id="contextStatus">Fill history and exam first to reuse their details.</span></div>
          <div class="context-grid" id="contextSummary"></div>
          <div class="context-actions" id="contextActions"></div>
        </section>
        <section class="panel assist-panel">
          <div class="panel-head"><h3>Physician Favorites</h3><span class="status" id="favoriteStatus">Save usual choices for this procedure.</span></div>
          <div class="favorite-grid">
            <select id="favoriteSelect"><option value="">No saved favorite</option></select>
            <button class="btn" id="applyFavorite">Apply</button>
            <button class="btn primary" id="saveFavorite">Save Current</button>
            <button class="btn danger" id="deleteFavorite">Delete</button>
            <input id="favoriteName" placeholder="Favorite name, e.g. My usual right knee PRP" style="grid-column: 1 / -1;">
          </div>
        </section>
        <section class="panel assist-panel">
          <div class="panel-head"><h3>Structured Encounter Inputs</h3><span class="status" id="defaultRule">Encounter input → per-form → global → blank</span></div>
          <div class="fields" id="fields"></div>
        </section>
      </main>
      <aside class="preview">
        <div class="preview-inner">
          <p class="section-title">Narrative EMR Output</p>
          <div class="missing" id="missing"></div>
          <div class="note" id="note"></div>
          <div class="product-box" id="products"></div>
          <div class="review-box">
            <div class="panel-head"><h3>Physician Review</h3><span class="review-status blocked" id="reviewStatus">Not ready</span></div>
            <div class="review-body">
              <label class="review-item"><input type="checkbox" data-review="required"> <span>All required manual fields match the encounter.</span></label>
              <label class="review-item"><input type="checkbox" data-review="safety"> <span>Consent, time-out, allergies, infection screen, anticoagulants, side/site/level reviewed.</span></label>
              <label class="review-item"><input type="checkbox" data-review="products"> <span>Products/devices, concentration, dose/volume, lot/expiry, and verification status reviewed.</span></label>
              <label class="review-item"><input type="checkbox" data-review="narrative"> <span>Narrative output edited as needed and ready for EMR paste/signature.</span></label>
              <div class="review-grid">
                <input id="reviewerName" placeholder="Reviewer">
                <input id="reviewDate" type="date">
              </div>
              <textarea id="reviewNotes" placeholder="Review notes / exceptions"></textarea>
              <div class="review-actions">
                <button class="btn" id="copyReviewPacket">Copy Review Packet</button>
                <button class="btn" id="exportReviewPacket">Export Review TXT</button>
              </div>
            </div>
          </div>
        </div>
      </aside>
    </div>
  </div>
  <script id="epione-data" type="application/json">{"version": "v0.7", "clinic_context": {"clinic_name": "Epione Pain Centre", "location": "Thornhill, Ontario, Canada", "model": "Hybrid structured input -> layered defaults -> narrative EMR output", "scope": "Chronic pain out-of-hospital clinic documentation templates for histories, focused physical exams, and procedure notes. v0.6 adds product/device/default verification library."}, "global_defaults": {"clinic_name": "Epione Pain Centre", "province": "Ontario", "documentation_model": "Hybrid structured input with narrative EMR output", "consent_phrase": "The procedure, expected benefits, reasonable alternatives, and risks were reviewed, including bleeding, infection, pain flare, allergic reaction, vasovagal reaction, failure to improve, need for repeat treatment, and procedure-specific risks. The patient had the opportunity to ask questions and consented to proceed.", "timeout_phrase": "A procedural time-out was completed immediately before the procedure, confirming patient identity, procedure, side/site/level, relevant allergies, anticoagulant status, infection screen, and planned injectate/device settings.", "skin_prep": "Chlorhexidine skin preparation; allow to dry completely before needle entry. Use alternative if allergy/contraindication.", "sterile_setup": "Sterile gloves, sterile gel, sterile probe cover when ultrasound-guided, sterile drape as appropriate.", "ultrasound_guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "fluoroscopy_guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "image_storage_phrase": "Representative images were saved to the clinic imaging archive when technically feasible.", "default_monitoring_injection": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "default_monitoring_rfa": "Non-invasive monitoring was used as clinically indicated. The patient remained communicative during stimulation and lesioning unless otherwise documented.", "default_monitoring_infusion": "Continuous monitoring with serial vital signs, level of sedation/dissociation assessment, and rescue equipment immediately available per clinic protocol.", "post_procedure_instructions": "Post-procedure instructions and warning signs were reviewed, including new neurologic deficit, severe worsening pain, fever, drainage, allergic symptoms, chest pain, or shortness of breath. The patient was advised to seek urgent care if concerning symptoms occur.", "follow_up_plan": "Follow-up arranged according to response and treatment plan; patient advised to track pain, function, and adverse effects.", "product_verification_phrase": "Medication/product/device selection, DIN/licence status, lot number, expiry, concentration, and dose/volume must be verified on the day of procedure.", "default_chaperone_phrase": "Chaperone offered/used according to clinic policy and patient preference.", "rtf_export_note": "Generated procedure notes should be reviewed and edited by the physician before signing in the EMR.", "clinician_name": "Dr. Eiman Rahimi, MD, FRCPC", "clinic_location": "Thornhill, Ontario", "history_documentation_phrase": "Focused chronic pain history documented; patient-specific details must be reviewed and edited before signing.", "physical_exam_documentation_phrase": "Focused pain-relevant examination documented; patient-specific findings must be reviewed and edited before signing.", "default_history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response.", "default_exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk.", "image_guidance_compliance_phrase": "For adult chronic pain nerve blocks in an out-of-hospital premises, image-guidance expectations and documentation requirements should be checked against current CPSO OHP standards."}, "forms": [{"form_id": "knee_ia_steroid_us", "title": "Knee intra-articular corticosteroid injection - ultrasound-guided", "region": "Knee", "family": "Joint steroid injection", "conditions": ["Knee osteoarthritis", "Inflammatory arthropathy", "Chronic knee pain", "Recurrent effusion"], "template_sheet": "Knee_Steroid_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Supine with knee slightly flexed over a bolster", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Superolateral approach", "target": "Suprapatellar recess / intra-articular space", "needle": "22G 1.5-inch needle; longer needle if required by body habitus", "injectate_product": "Triamcinolone acetonide or methylprednisolone acetate - verify product and DIN", "dose_volume": "Physician-selected steroid dose with local anesthetic", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 3-6 mL; verify actual"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Steroid product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Steroid dose and anesthetic volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Knee Intra-Articular Corticosteroid Injection - Ultrasound-Guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via a {{approach}} to the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Joint steroid injection", "condition_tags": "Knee osteoarthritis; Inflammatory arthropathy; Chronic knee pain; Recurrent effusion", "sheet_name": "Knee_Steroid_US", "defaults": {"patient_position": "Supine with knee slightly flexed over a bolster", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Superolateral approach", "target": "Suprapatellar recess / intra-articular space", "needle": "22G 1.5-inch needle; longer needle if required by body habitus", "injectate_product": "Triamcinolone acetonide or methylprednisolone acetate - verify product and DIN", "dose_volume": "Physician-selected steroid dose with local anesthetic", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 3-6 mL; verify actual", "next_procedure_medication_choice": "Triamcinolone acetonide or methylprednisolone acetate - verify product and DIN", "next_procedure_dose": "Physician-selected steroid dose with local anesthetic; Typical total 3-6 mL; verify actual", "next_procedure_technique": "Ultrasound-guided, in-plane; Superolateral approach; Suprapatellar recess / intra-articular space; 22G 1.5-inch needle; longer needle if required by body habitus", "next_procedure_patient_position": "Supine with knee slightly flexed over a bolster", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Knee Intra-Articular Corticosteroid Injection - Ultrasound-Guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via a {{approach}} to the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Knee", "condition": "Knee osteoarthritis / chronic knee pain", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Joint injections"}}, {"form_id": "knee_ia_ha_us", "title": "Knee intra-articular hyaluronic acid injection - ultrasound-guided", "region": "Knee", "family": "Hyaluronic acid injection", "conditions": ["Knee osteoarthritis", "Chronic degenerative knee pain"], "template_sheet": "Knee_HA_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Supine with knee slightly flexed over a bolster", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Superolateral approach", "target": "Suprapatellar recess / intra-articular space", "needle": "21-22G needle sized to product viscosity and patient habitus", "injectate_product": "Hyaluronic acid product selected according to availability, patient affordability, and product indication - verify DIN/device status as applicable", "dose_volume": "Product-specific syringe volume", "diluent_anesthetic": "Usually none intra-articularly unless clinically selected; local skin wheal optional", "total_volume": "Product-specific volume"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "HA product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "HA product volume / series number", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Product Series", "key": "series_number", "label": "Series number / injection number", "default_layer": "No Default", "input_type": "text", "required": true, "options": "1 of 1;1 of 3;2 of 3;3 of 3", "help": "Manual-only series tracking."}, {"section": "Product Series", "key": "prior_ha_response", "label": "Prior HA response if repeat series", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only response history."}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Knee Intra-Articular Hyaluronic Acid Injection - Ultrasound-Guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via a {{approach}} to the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}; series: {{series_number}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Hyaluronic acid injection", "condition_tags": "Knee osteoarthritis; Chronic degenerative knee pain", "sheet_name": "Knee_HA_US", "defaults": {"patient_position": "Supine with knee slightly flexed over a bolster", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Superolateral approach", "target": "Suprapatellar recess / intra-articular space", "needle": "21-22G needle sized to product viscosity and patient habitus", "injectate_product": "Hyaluronic acid product selected according to availability, patient affordability, and product indication - verify DIN/device status as applicable", "dose_volume": "Product-specific syringe volume", "diluent_anesthetic": "Usually none intra-articularly unless clinically selected; local skin wheal optional", "total_volume": "Product-specific volume", "next_procedure_medication_choice": "Hyaluronic acid product selected according to availability, patient affordability, and product indication - verify DIN/device status as applicable", "next_procedure_dose": "Product-specific syringe volume; Product-specific volume", "next_procedure_technique": "Ultrasound-guided, in-plane; Superolateral approach; Suprapatellar recess / intra-articular space; 21-22G needle sized to product viscosity and patient habitus", "next_procedure_patient_position": "Supine with knee slightly flexed over a bolster", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Knee Intra-Articular Hyaluronic Acid Injection - Ultrasound-Guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via a {{approach}} to the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}; series: {{series_number}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Knee", "condition": "Knee osteoarthritis / chronic knee pain", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regenerative / viscosupplementation", "procedure_group": "Joint injections"}}, {"form_id": "knee_ia_prp_us", "title": "Knee intra-articular PRP injection - ultrasound-guided", "region": "Knee", "family": "PRP injection", "conditions": ["Knee osteoarthritis", "Post-traumatic knee pain", "Degenerative meniscal symptoms"], "template_sheet": "Knee_PRP_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Supine with knee slightly flexed over a bolster", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Superolateral approach", "target": "Suprapatellar recess / intra-articular space", "needle": "21-22G needle sized to PRP viscosity and patient habitus", "injectate_product": "Autologous PRP prepared using clinic-selected Health Canada-compliant collection/preparation system", "dose_volume": "PRP volume per treatment plan", "diluent_anesthetic": "Avoid intra-articular local anesthetic unless physician deliberately selects; local skin anesthesia optional", "total_volume": "Actual PRP volume injected"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "PRP product/preparation", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "PRP volume injected", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "PRP Preparation", "key": "prp_system", "label": "PRP system / kit", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify device/licence and clinic protocol."}, {"section": "PRP Preparation", "key": "blood_draw_volume", "label": "Blood draw volume", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual volume."}, {"section": "PRP Preparation", "key": "spin_protocol", "label": "Spin protocol / processing details", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Procedure-specific default, edit per actual kit/protocol."}, {"section": "PRP Preparation", "key": "leukocyte_status", "label": "Leukocyte-rich / leukocyte-poor / not measured", "default_layer": "No Default", "input_type": "select", "required": false, "options": "Leukocyte-poor;Leukocyte-rich;Not measured", "help": "Manual or device-specific."}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Knee Intra-Articular PRP Injection - Ultrasound-Guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Autologous PRP was prepared using {{prp_system}}. Processing details: {{spin_protocol}}. Using {{guidance}}, a {{needle}} was advanced via a {{approach}} to the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}; leukocyte status: {{leukocyte_status}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nPRP preparation: Blood draw volume: {{blood_draw_volume}}. System/kit: {{prp_system}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "PRP injection", "condition_tags": "Knee osteoarthritis; Post-traumatic knee pain; Degenerative meniscal symptoms", "sheet_name": "Knee_PRP_US", "defaults": {"patient_position": "Supine with knee slightly flexed over a bolster", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Superolateral approach", "target": "Suprapatellar recess / intra-articular space", "needle": "21-22G needle sized to PRP viscosity and patient habitus", "injectate_product": "Autologous PRP prepared using clinic-selected Health Canada-compliant collection/preparation system", "dose_volume": "PRP volume per treatment plan", "diluent_anesthetic": "Avoid intra-articular local anesthetic unless physician deliberately selects; local skin anesthesia optional", "total_volume": "Actual PRP volume injected", "next_procedure_medication_choice": "Autologous PRP prepared using clinic-selected Health Canada-compliant collection/preparation system", "next_procedure_dose": "PRP volume per treatment plan; Actual PRP volume injected", "next_procedure_technique": "Ultrasound-guided, in-plane; Superolateral approach; Suprapatellar recess / intra-articular space; 21-22G needle sized to PRP viscosity and patient habitus", "next_procedure_patient_position": "Supine with knee slightly flexed over a bolster", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Knee Intra-Articular PRP Injection - Ultrasound-Guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Autologous PRP was prepared using {{prp_system}}. Processing details: {{spin_protocol}}. Using {{guidance}}, a {{needle}} was advanced via a {{approach}} to the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}; leukocyte status: {{leukocyte_status}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nPRP preparation: Blood draw volume: {{blood_draw_volume}}. System/kit: {{prp_system}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Knee", "condition": "Knee osteoarthritis / chronic knee pain", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regenerative / viscosupplementation", "procedure_group": "Joint injections"}}, {"form_id": "knee_periarticular_prolo_us", "title": "Knee periarticular prolotherapy - ultrasound-guided", "region": "Knee", "family": "Prolotherapy", "conditions": ["Knee ligament laxity", "Chronic periarticular knee pain", "Patellofemoral pain with soft tissue pain"], "template_sheet": "Knee_Prolo_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Supine or side-lying depending on sites treated", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided where indicated plus palpation-guided superficial enthesis targeting as appropriate", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Site-specific short-axis or long-axis approach", "target": "Tender entheses/ligamentous attachments around knee; avoid neurovascular structures", "needle": "25G or 27G needle for superficial entheses; longer needle if required", "injectate_product": "Dextrose-based prolotherapy solution prepared per clinic protocol", "dose_volume": "Small aliquots per enthesis/site", "diluent_anesthetic": "Physician-selected diluent/local anesthetic if used", "total_volume": "Actual total volume across all sites"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Prolotherapy solution", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Concentration and aliquot volumes", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Technique", "key": "sites_treated", "label": "Exact sites treated", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only. List each site/enthesis."}, {"section": "Technique", "key": "number_of_needle_placements", "label": "Number of needle placements", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual count."}, {"section": "Technique", "key": "neurovascular_avoidance", "label": "Neurovascular structures identified/avoided", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only safety documentation."}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Knee Periarticular Prolotherapy - Ultrasound-Guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}}, the {{needle}} was used via {{approach}} to treat {{sites_treated}} targeting {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nSites/count: Sites treated: {{sites_treated}}. Needle placements: {{number_of_needle_placements}}. Neurovascular safety: {{neurovascular_avoidance}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Prolotherapy", "condition_tags": "Knee ligament laxity; Chronic periarticular knee pain; Patellofemoral pain with soft tissue pain", "sheet_name": "Knee_Prolo_US", "defaults": {"patient_position": "Supine or side-lying depending on sites treated", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided where indicated plus palpation-guided superficial enthesis targeting as appropriate", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Site-specific short-axis or long-axis approach", "target": "Tender entheses/ligamentous attachments around knee; avoid neurovascular structures", "needle": "25G or 27G needle for superficial entheses; longer needle if required", "injectate_product": "Dextrose-based prolotherapy solution prepared per clinic protocol", "dose_volume": "Small aliquots per enthesis/site", "diluent_anesthetic": "Physician-selected diluent/local anesthetic if used", "total_volume": "Actual total volume across all sites", "next_procedure_medication_choice": "Dextrose-based prolotherapy solution prepared per clinic protocol", "next_procedure_dose": "Small aliquots per enthesis/site; Actual total volume across all sites", "next_procedure_technique": "Ultrasound-guided where indicated plus palpation-guided superficial enthesis targeting as appropriate; Site-specific short-axis or long-axis approach; Tender entheses/ligamentous attachments around knee; avoid neurovascular structures; 25G or 27G needle for superficial entheses; longer needle if required", "next_procedure_patient_position": "Supine or side-lying depending on sites treated", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Knee Periarticular Prolotherapy - Ultrasound-Guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}}, the {{needle}} was used via {{approach}} to treat {{sites_treated}} targeting {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nSites/count: Sites treated: {{sites_treated}}. Needle placements: {{number_of_needle_placements}}. Neurovascular safety: {{neurovascular_avoidance}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Knee", "condition": "Knee osteoarthritis / chronic knee pain", "guidance_options": ["Ultrasound-guided", "Landmark-guided"], "intervention_type": "Regenerative / viscosupplementation", "procedure_group": "Office-based pain procedure"}}, {"form_id": "genicular_rfa", "title": "Genicular nerve radiofrequency ablation", "region": "Knee", "family": "Radiofrequency ablation", "conditions": ["Knee osteoarthritis", "Post-arthroplasty knee pain", "Chronic knee pain after successful diagnostic block"], "template_sheet": "Genicular_RFA", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Supine with knee slightly flexed and supported", "monitoring": "Non-invasive monitoring was used as clinically indicated. The patient remained communicative during stimulation and lesioning unless otherwise documented.", "guidance": "Fluoroscopy or ultrasound according to clinic protocol and anatomy", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "imaging_modality": "Fluoroscopy; ultrasound as adjunct if used", "cannula": "RF cannula sized to target depth and selected active tip", "generator": "Clinic RF generator - verify device and settings", "electrode_orientation": "Cannula positioned at bony targets corresponding to superior medial, superior lateral, and inferior medial genicular nerve regions or documented targets", "lesion_settings": "Conventional RF settings per clinic protocol; document actual temperature/time", "post_lesion_injectate": "Small volume local anesthetic +/- steroid if selected and appropriate"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from fluoroscopy_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Targets", "key": "levels_targets", "label": "Levels / nerves targeted", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only: exact levels/nerves treated.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "imaging_modality", "label": "Imaging modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if different."}, {"section": "Technique", "key": "cannula", "label": "RF cannula / active tip", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default."}, {"section": "Technique", "key": "generator", "label": "RF generator / technology", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify device and availability."}, {"section": "Technique", "key": "electrode_orientation", "label": "Electrode orientation / lesion geometry", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Procedure-specific technique detail."}, {"section": "Stimulation", "key": "sensory_stimulation", "label": "Sensory stimulation result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual test result."}, {"section": "Stimulation", "key": "motor_stimulation", "label": "Motor stimulation result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual motor response."}, {"section": "Lesioning", "key": "lesion_settings", "label": "Lesion temperature/time/settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual setting."}, {"section": "Lesioning", "key": "number_of_lesions", "label": "Number of lesions", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual count."}, {"section": "Lesioning", "key": "post_lesion_injectate", "label": "Post-lesion injectate", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Editable procedure-specific default."}, {"section": "Outcome", "key": "post_procedure_neuro_status", "label": "Post-procedure neurologic status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual exam/status.", "quick_options": ["No immediate complication observed.", "Response will be reassessed after the expected onset window."]}, {"section": "Targets", "key": "diagnostic_block_response", "label": "Diagnostic block response supporting RFA", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only RFA indication."}, {"section": "Safety", "key": "anticoagulant_hold_details", "label": "Anticoagulant/antiplatelet plan", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only if relevant.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Genicular Nerve Radiofrequency Ablation\n\nIndication: {{side}} genicular RFA for {{diagnosis}}. Diagnostic block response: {{diagnostic_block_response}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup/guidance: Position: {{patient_position}}. Monitoring: {{monitoring}}. Guidance: {{imaging_modality}}. Images: {{image_saved}}\n\nTargets: {{levels_targets}}. Cannula: {{cannula}}. Generator: {{generator}}. Orientation: {{electrode_orientation}}\n\nStimulation/lesioning: Sensory stimulation: {{sensory_stimulation}} Motor stimulation: {{motor_stimulation}} Settings: {{lesion_settings}} Number of lesions: {{number_of_lesions}}. Post-lesion injectate: {{post_lesion_injectate}}\n\nOutcome: Neuro status: {{post_procedure_neuro_status}}. Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Radiofrequency ablation", "condition_tags": "Knee osteoarthritis; Post-arthroplasty knee pain; Chronic knee pain after successful diagnostic block", "sheet_name": "Genicular_RFA", "defaults": {"patient_position": "Supine with knee slightly flexed and supported", "monitoring": "Non-invasive monitoring was used as clinically indicated. The patient remained communicative during stimulation and lesioning unless otherwise documented.", "guidance": "Fluoroscopy or ultrasound according to clinic protocol and anatomy", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "imaging_modality": "Fluoroscopy; ultrasound as adjunct if used", "cannula": "RF cannula sized to target depth and selected active tip", "generator": "Clinic RF generator - verify device and settings", "electrode_orientation": "Cannula positioned at bony targets corresponding to superior medial, superior lateral, and inferior medial genicular nerve regions or documented targets", "lesion_settings": "Conventional RF settings per clinic protocol; document actual temperature/time", "post_lesion_injectate": "Small volume local anesthetic +/- steroid if selected and appropriate", "next_procedure_medication_choice": "Small volume local anesthetic +/- steroid if selected and appropriate", "next_procedure_dose": "Conventional RF settings per clinic protocol; document actual temperature/time", "next_procedure_technique": "Fluoroscopy or ultrasound according to clinic protocol and anatomy; RF cannula sized to target depth and selected active tip", "next_procedure_patient_position": "Supine with knee slightly flexed and supported", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating nerve ablation/RFA, usual interval is about every year or longer unless physician documents a different rationale; reassess indication, diagnostic response, neurologic status, and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Genicular Nerve Radiofrequency Ablation\n\nIndication: {{side}} genicular RFA for {{diagnosis}}. Diagnostic block response: {{diagnostic_block_response}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup/guidance: Position: {{patient_position}}. Monitoring: {{monitoring}}. Guidance: {{imaging_modality}}. Images: {{image_saved}}\n\nTargets: {{levels_targets}}. Cannula: {{cannula}}. Generator: {{generator}}. Orientation: {{electrode_orientation}}\n\nStimulation/lesioning: Sensory stimulation: {{sensory_stimulation}} Motor stimulation: {{motor_stimulation}} Settings: {{lesion_settings}} Number of lesions: {{number_of_lesions}}. Post-lesion injectate: {{post_lesion_injectate}}\n\nOutcome: Neuro status: {{post_procedure_neuro_status}}. Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Knee", "condition": "Knee osteoarthritis / chronic knee pain", "guidance_options": ["Ultrasound-guided", "Fluoroscopy-guided"], "intervention_type": "Ablation / PRF", "procedure_group": "Ablation / neuromodulation"}}, {"form_id": "hip_ia_steroid_us", "title": "Hip intra-articular corticosteroid injection - ultrasound-guided", "region": "Hip", "family": "Joint steroid injection", "conditions": ["Hip osteoarthritis", "Femoroacetabular impingement pain", "Inflammatory hip arthropathy"], "template_sheet": "Hip_Steroid_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Supine with hip in neutral rotation", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "Low-frequency curvilinear transducer or linear transducer depending on habitus", "approach": "Anterior longitudinal in-plane approach", "target": "Femoral head-neck junction / anterior capsular recess", "needle": "22G spinal needle or echogenic needle sized to depth", "injectate_product": "Physician-selected corticosteroid product - verify product and DIN", "dose_volume": "Physician-selected steroid dose with local anesthetic", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 4-8 mL; verify actual"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Hip intra-articular corticosteroid injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via an {{approach}} to the {{target}}, avoiding femoral neurovascular structures. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Joint steroid injection", "condition_tags": "Hip osteoarthritis; Femoroacetabular impingement pain; Inflammatory hip arthropathy", "sheet_name": "Hip_Steroid_US", "defaults": {"patient_position": "Supine with hip in neutral rotation", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "Low-frequency curvilinear transducer or linear transducer depending on habitus", "approach": "Anterior longitudinal in-plane approach", "target": "Femoral head-neck junction / anterior capsular recess", "needle": "22G spinal needle or echogenic needle sized to depth", "injectate_product": "Physician-selected corticosteroid product - verify product and DIN", "dose_volume": "Physician-selected steroid dose with local anesthetic", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 4-8 mL; verify actual", "next_procedure_medication_choice": "Physician-selected corticosteroid product - verify product and DIN", "next_procedure_dose": "Physician-selected steroid dose with local anesthetic; Typical total 4-8 mL; verify actual", "next_procedure_technique": "Ultrasound-guided, in-plane; Anterior longitudinal in-plane approach; Femoral head-neck junction / anterior capsular recess; 22G spinal needle or echogenic needle sized to depth", "next_procedure_patient_position": "Supine with hip in neutral rotation", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Hip intra-articular corticosteroid injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via an {{approach}} to the {{target}}, avoiding femoral neurovascular structures. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Hip osteoarthritis / chronic groin pain", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Joint injections"}}, {"form_id": "hip_ia_prp_us", "title": "Hip intra-articular PRP injection - ultrasound-guided", "region": "Hip", "family": "PRP injection", "conditions": ["Hip osteoarthritis", "Chronic hip pain", "Labral/degenerative hip pain where appropriate"], "template_sheet": "Hip_PRP_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Supine with hip in neutral rotation", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "Low-frequency curvilinear transducer or linear transducer depending on habitus", "approach": "Anterior longitudinal in-plane approach", "target": "Femoral head-neck junction / anterior capsular recess", "needle": "22G spinal needle or echogenic needle sized to depth", "injectate_product": "Autologous PRP prepared using clinic-selected Health Canada-compliant collection/preparation system", "dose_volume": "PRP volume per treatment plan", "diluent_anesthetic": "Avoid intra-articular local anesthetic unless deliberately selected; local skin anesthesia optional", "total_volume": "Actual PRP volume injected", "prp_system": "Clinic-selected PRP kit/system - verify device/licence", "spin_protocol": "Prepare according to kit manufacturer instructions and clinic protocol"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "PRP product/preparation", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "PRP volume injected", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "PRP Preparation", "key": "prp_system", "label": "PRP system / kit", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify device/licence and clinic protocol."}, {"section": "PRP Preparation", "key": "blood_draw_volume", "label": "Blood draw volume", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual volume."}, {"section": "PRP Preparation", "key": "spin_protocol", "label": "Spin protocol / processing details", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Procedure-specific default, edit per actual kit/protocol."}, {"section": "Technique", "key": "fenestration_pattern", "label": "Fenestration/peppering pattern if performed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only actual technique."}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Hip intra-articular PRP injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Autologous PRP was prepared. Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via an {{approach}} to the {{target}}, avoiding femoral neurovascular structures. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nPRP preparation: System: {{prp_system}}. Blood draw volume: {{blood_draw_volume}}. Spin protocol: {{spin_protocol}}. Fenestration: {{fenestration_pattern}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "PRP injection", "condition_tags": "Hip osteoarthritis; Chronic hip pain; Labral/degenerative hip pain where appropriate", "sheet_name": "Hip_PRP_US", "defaults": {"patient_position": "Supine with hip in neutral rotation", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "Low-frequency curvilinear transducer or linear transducer depending on habitus", "approach": "Anterior longitudinal in-plane approach", "target": "Femoral head-neck junction / anterior capsular recess", "needle": "22G spinal needle or echogenic needle sized to depth", "injectate_product": "Autologous PRP prepared using clinic-selected Health Canada-compliant collection/preparation system", "dose_volume": "PRP volume per treatment plan", "diluent_anesthetic": "Avoid intra-articular local anesthetic unless deliberately selected; local skin anesthesia optional", "total_volume": "Actual PRP volume injected", "prp_system": "Clinic-selected PRP kit/system - verify device/licence", "spin_protocol": "Prepare according to kit manufacturer instructions and clinic protocol", "next_procedure_medication_choice": "Autologous PRP prepared using clinic-selected Health Canada-compliant collection/preparation system", "next_procedure_dose": "PRP volume per treatment plan; Actual PRP volume injected", "next_procedure_technique": "Ultrasound-guided, in-plane; Anterior longitudinal in-plane approach; Femoral head-neck junction / anterior capsular recess; 22G spinal needle or echogenic needle sized to depth", "next_procedure_patient_position": "Supine with hip in neutral rotation", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Hip intra-articular PRP injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Autologous PRP was prepared. Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via an {{approach}} to the {{target}}, avoiding femoral neurovascular structures. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nPRP preparation: System: {{prp_system}}. Blood draw volume: {{blood_draw_volume}}. Spin protocol: {{spin_protocol}}. Fenestration: {{fenestration_pattern}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Hip osteoarthritis / chronic groin pain", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regenerative / viscosupplementation", "procedure_group": "Joint injections"}}, {"form_id": "gt_bursa_gluteal_tendon_steroid_us", "title": "Greater trochanteric bursa / gluteal tendon region injection - ultrasound-guided", "region": "Hip / lateral hip", "family": "Bursa/tendon region steroid injection", "conditions": ["Greater trochanteric pain syndrome", "Trochanteric bursitis", "Gluteal tendinopathy"], "template_sheet": "GT_Bursa_Tendon_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Lateral decubitus with symptomatic side up", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer or curvilinear if needed", "approach": "Lateral in-plane approach", "target": "Trochanteric bursa/peritendinous plane adjacent to gluteus medius/minimus insertion; avoid intratendinous steroid injection", "needle": "22G 1.5-3.5 inch needle based on depth", "injectate_product": "Physician-selected corticosteroid product - verify product and DIN", "dose_volume": "Physician-selected steroid dose with local anesthetic", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 4-8 mL; verify actual"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Greater trochanteric bursa / gluteal tendon region injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via a {{approach}} into the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Bursa/tendon region steroid injection", "condition_tags": "Greater trochanteric pain syndrome; Trochanteric bursitis; Gluteal tendinopathy", "sheet_name": "GT_Bursa_Tendon_US", "defaults": {"patient_position": "Lateral decubitus with symptomatic side up", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer or curvilinear if needed", "approach": "Lateral in-plane approach", "target": "Trochanteric bursa/peritendinous plane adjacent to gluteus medius/minimus insertion; avoid intratendinous steroid injection", "needle": "22G 1.5-3.5 inch needle based on depth", "injectate_product": "Physician-selected corticosteroid product - verify product and DIN", "dose_volume": "Physician-selected steroid dose with local anesthetic", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 4-8 mL; verify actual", "next_procedure_medication_choice": "Physician-selected corticosteroid product - verify product and DIN", "next_procedure_dose": "Physician-selected steroid dose with local anesthetic; Typical total 4-8 mL; verify actual", "next_procedure_technique": "Ultrasound-guided, in-plane; Lateral in-plane approach; Trochanteric bursa/peritendinous plane adjacent to gluteus medius/minimus insertion; avoid intratendinous steroid injection; 22G 1.5-3.5 inch needle based on depth", "next_procedure_patient_position": "Lateral decubitus with symptomatic side up", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Greater trochanteric bursa / gluteal tendon region injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via a {{approach}} into the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Greater trochanteric pain syndrome", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regenerative / viscosupplementation", "procedure_group": "Tendon / enthesis procedures"}}, {"form_id": "piriformis_injection_us", "title": "Piriformis muscle injection - ultrasound-guided", "region": "Hip / buttock", "family": "Deep muscle injection", "conditions": ["Piriformis syndrome", "Deep gluteal pain syndrome", "Sciatic-type buttock pain after evaluation"], "template_sheet": "Piriformis_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Prone or lateral decubitus with hip internally rotated as needed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "Curvilinear transducer", "approach": "Posterolateral in-plane approach", "target": "Piriformis muscle belly/perimuscular plane while identifying sciatic nerve", "needle": "22G spinal needle or echogenic needle sized to depth", "injectate_product": "Local anesthetic +/- corticosteroid per treatment plan", "dose_volume": "Physician-selected dose/volume", "diluent_anesthetic": "Local anesthetic as selected", "total_volume": "Typical total 3-8 mL; verify actual"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Piriformis muscle injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, the sciatic nerve and piriformis were identified, and a {{needle}} was advanced via a {{approach}} to the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Deep muscle injection", "condition_tags": "Piriformis syndrome; Deep gluteal pain syndrome; Sciatic-type buttock pain after evaluation", "sheet_name": "Piriformis_US", "defaults": {"patient_position": "Prone or lateral decubitus with hip internally rotated as needed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "Curvilinear transducer", "approach": "Posterolateral in-plane approach", "target": "Piriformis muscle belly/perimuscular plane while identifying sciatic nerve", "needle": "22G spinal needle or echogenic needle sized to depth", "injectate_product": "Local anesthetic +/- corticosteroid per treatment plan", "dose_volume": "Physician-selected dose/volume", "diluent_anesthetic": "Local anesthetic as selected", "total_volume": "Typical total 3-8 mL; verify actual", "next_procedure_medication_choice": "Local anesthetic +/- corticosteroid per treatment plan", "next_procedure_dose": "Physician-selected dose/volume; Typical total 3-8 mL; verify actual", "next_procedure_technique": "Ultrasound-guided, in-plane; Posterolateral in-plane approach; Piriformis muscle belly/perimuscular plane while identifying sciatic nerve; 22G spinal needle or echogenic needle sized to depth", "next_procedure_patient_position": "Prone or lateral decubitus with hip internally rotated as needed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Piriformis muscle injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, the sciatic nerve and piriformis were identified, and a {{needle}} was advanced via a {{approach}} to the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Piriformis / deep gluteal pain", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Office-based pain procedure"}}, {"form_id": "si_joint_steroid_us", "title": "Sacroiliac joint corticosteroid injection - ultrasound-guided", "region": "Pelvis / SI joint", "family": "Joint steroid injection", "conditions": ["Sacroiliac joint pain", "Inflammatory sacroiliitis where appropriate", "Mechanical SI joint pain"], "template_sheet": "SIJ_Steroid_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Prone with pillow support as needed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane or out-of-plane according to anatomy", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "Curvilinear transducer", "approach": "Inferior/posterior approach to accessible SI joint recess", "target": "Posterior/inferior SI joint recess or periarticular SI region if intra-articular access limited", "needle": "22G spinal needle or echogenic needle sized to depth", "injectate_product": "Physician-selected corticosteroid product - verify product and DIN", "dose_volume": "Physician-selected steroid dose with local anesthetic", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 2-5 mL; verify actual"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Sacroiliac joint corticosteroid injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via a {{approach}} to the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Joint steroid injection", "condition_tags": "Sacroiliac joint pain; Inflammatory sacroiliitis where appropriate; Mechanical SI joint pain", "sheet_name": "SIJ_Steroid_US", "defaults": {"patient_position": "Prone with pillow support as needed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane or out-of-plane according to anatomy", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "Curvilinear transducer", "approach": "Inferior/posterior approach to accessible SI joint recess", "target": "Posterior/inferior SI joint recess or periarticular SI region if intra-articular access limited", "needle": "22G spinal needle or echogenic needle sized to depth", "injectate_product": "Physician-selected corticosteroid product - verify product and DIN", "dose_volume": "Physician-selected steroid dose with local anesthetic", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 2-5 mL; verify actual", "next_procedure_medication_choice": "Physician-selected corticosteroid product - verify product and DIN", "next_procedure_dose": "Physician-selected steroid dose with local anesthetic; Typical total 2-5 mL; verify actual", "next_procedure_technique": "Ultrasound-guided, in-plane or out-of-plane according to anatomy; Inferior/posterior approach to accessible SI joint recess; Posterior/inferior SI joint recess or periarticular SI region if intra-articular access limited; 22G spinal needle or echogenic needle sized to depth", "next_procedure_patient_position": "Prone with pillow support as needed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Sacroiliac joint corticosteroid injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via a {{approach}} to the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Sacroiliac joint pain / posterior pelvic pain", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regenerative / viscosupplementation", "procedure_group": "Joint injections"}}, {"form_id": "si_ligament_prolo_us", "title": "Sacroiliac / posterior pelvic ligament prolotherapy - ultrasound-guided", "region": "Pelvis / SI joint", "family": "Prolotherapy", "conditions": ["SI ligament laxity", "Posterior pelvic ligament pain", "Chronic mechanical SI pain"], "template_sheet": "SIJ_Prolo_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Prone with pillow support as needed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided where indicated plus palpation-guided superficial enthesis targeting as appropriate", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "Curvilinear or linear transducer depending on site/depth", "approach": "Site-specific approach to posterior SI ligament/iliolumbar/sacrotuberous attachments", "target": "Tender posterior pelvic ligamentous attachments; avoid sacral foramina and neurovascular structures", "needle": "25G or 22G needle based on depth", "injectate_product": "Dextrose-based prolotherapy solution prepared per clinic protocol", "dose_volume": "Small aliquots per site", "diluent_anesthetic": "Physician-selected diluent/local anesthetic if used", "total_volume": "Actual total volume across all sites"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Prolotherapy solution", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Concentration and aliquot volumes", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Technique", "key": "sites_treated", "label": "Exact sites treated", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only. List each site/enthesis."}, {"section": "Technique", "key": "number_of_needle_placements", "label": "Number of needle placements", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual count."}, {"section": "Technique", "key": "neurovascular_avoidance", "label": "Neurovascular structures identified/avoided", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only safety documentation."}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Sacroiliac / posterior pelvic ligament prolotherapy - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}}, the {{needle}} was used via {{approach}} to treat {{sites_treated}} targeting {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nSites/count: Sites treated: {{sites_treated}}. Needle placements: {{number_of_needle_placements}}. Neurovascular safety: {{neurovascular_avoidance}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Prolotherapy", "condition_tags": "SI ligament laxity; Posterior pelvic ligament pain; Chronic mechanical SI pain", "sheet_name": "SIJ_Prolo_US", "defaults": {"patient_position": "Prone with pillow support as needed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided where indicated plus palpation-guided superficial enthesis targeting as appropriate", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "Curvilinear or linear transducer depending on site/depth", "approach": "Site-specific approach to posterior SI ligament/iliolumbar/sacrotuberous attachments", "target": "Tender posterior pelvic ligamentous attachments; avoid sacral foramina and neurovascular structures", "needle": "25G or 22G needle based on depth", "injectate_product": "Dextrose-based prolotherapy solution prepared per clinic protocol", "dose_volume": "Small aliquots per site", "diluent_anesthetic": "Physician-selected diluent/local anesthetic if used", "total_volume": "Actual total volume across all sites", "next_procedure_medication_choice": "Dextrose-based prolotherapy solution prepared per clinic protocol", "next_procedure_dose": "Small aliquots per site; Actual total volume across all sites", "next_procedure_technique": "Ultrasound-guided where indicated plus palpation-guided superficial enthesis targeting as appropriate; Site-specific approach to posterior SI ligament/iliolumbar/sacrotuberous attachments; Tender posterior pelvic ligamentous attachments; avoid sacral foramina and neurovascular structures; 25G or 22G needle based on depth", "next_procedure_patient_position": "Prone with pillow support as needed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Sacroiliac / posterior pelvic ligament prolotherapy - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}}, the {{needle}} was used via {{approach}} to treat {{sites_treated}} targeting {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nSites/count: Sites treated: {{sites_treated}}. Needle placements: {{number_of_needle_placements}}. Neurovascular safety: {{neurovascular_avoidance}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Sacroiliac joint pain / posterior pelvic pain", "guidance_options": ["Ultrasound-guided", "Landmark-guided"], "intervention_type": "Regenerative / viscosupplementation", "procedure_group": "Office-based pain procedure"}}, {"form_id": "shoulder_gh_steroid_us", "title": "Shoulder glenohumeral joint corticosteroid injection - ultrasound-guided", "region": "Shoulder", "family": "Joint steroid injection", "conditions": ["Glenohumeral osteoarthritis", "Adhesive capsulitis", "Inflammatory shoulder arthropathy"], "template_sheet": "GH_Steroid_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Sitting or lateral decubitus with posterior shoulder exposed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Posterior in-plane approach", "target": "Posterior glenohumeral joint recess between humeral head and glenoid labrum", "needle": "22G 1.5-3.5 inch needle based on depth", "injectate_product": "Physician-selected corticosteroid product - verify product and DIN", "dose_volume": "Physician-selected steroid dose with local anesthetic", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 4-8 mL; verify actual"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Shoulder glenohumeral joint corticosteroid injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via a {{approach}} to the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Joint steroid injection", "condition_tags": "Glenohumeral osteoarthritis; Adhesive capsulitis; Inflammatory shoulder arthropathy", "sheet_name": "GH_Steroid_US", "defaults": {"patient_position": "Sitting or lateral decubitus with posterior shoulder exposed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Posterior in-plane approach", "target": "Posterior glenohumeral joint recess between humeral head and glenoid labrum", "needle": "22G 1.5-3.5 inch needle based on depth", "injectate_product": "Physician-selected corticosteroid product - verify product and DIN", "dose_volume": "Physician-selected steroid dose with local anesthetic", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 4-8 mL; verify actual", "next_procedure_medication_choice": "Physician-selected corticosteroid product - verify product and DIN", "next_procedure_dose": "Physician-selected steroid dose with local anesthetic; Typical total 4-8 mL; verify actual", "next_procedure_technique": "Ultrasound-guided, in-plane; Posterior in-plane approach; Posterior glenohumeral joint recess between humeral head and glenoid labrum; 22G 1.5-3.5 inch needle based on depth", "next_procedure_patient_position": "Sitting or lateral decubitus with posterior shoulder exposed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Shoulder glenohumeral joint corticosteroid injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via a {{approach}} to the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Shoulder", "condition": "Shoulder osteoarthritis / adhesive capsulitis", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Epidural steroid injections (ESI)"}}, {"form_id": "shoulder_subacromial_steroid_us", "title": "Subacromial-subdeltoid bursa corticosteroid injection - ultrasound-guided", "region": "Shoulder", "family": "Bursa/tendon region steroid injection", "conditions": ["Subacromial bursitis", "Rotator cuff tendinopathy", "Impingement-type shoulder pain"], "template_sheet": "Subacromial_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Sitting with arm resting in internal rotation or modified Crass position", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Lateral-to-medial in-plane approach", "target": "Subacromial-subdeltoid bursal plane superficial to rotator cuff; avoid intratendinous steroid injection", "needle": "25G or 22G 1.5-inch needle", "injectate_product": "Physician-selected corticosteroid product - verify product and DIN", "dose_volume": "Physician-selected steroid dose with local anesthetic", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 4-8 mL; verify actual"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Subacromial-subdeltoid bursa corticosteroid injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via a {{approach}} to the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Bursa/tendon region steroid injection", "condition_tags": "Subacromial bursitis; Rotator cuff tendinopathy; Impingement-type shoulder pain", "sheet_name": "Subacromial_US", "defaults": {"patient_position": "Sitting with arm resting in internal rotation or modified Crass position", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Lateral-to-medial in-plane approach", "target": "Subacromial-subdeltoid bursal plane superficial to rotator cuff; avoid intratendinous steroid injection", "needle": "25G or 22G 1.5-inch needle", "injectate_product": "Physician-selected corticosteroid product - verify product and DIN", "dose_volume": "Physician-selected steroid dose with local anesthetic", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 4-8 mL; verify actual", "next_procedure_medication_choice": "Physician-selected corticosteroid product - verify product and DIN", "next_procedure_dose": "Physician-selected steroid dose with local anesthetic; Typical total 4-8 mL; verify actual", "next_procedure_technique": "Ultrasound-guided, in-plane; Lateral-to-medial in-plane approach; Subacromial-subdeltoid bursal plane superficial to rotator cuff; avoid intratendinous steroid injection; 25G or 22G 1.5-inch needle", "next_procedure_patient_position": "Sitting with arm resting in internal rotation or modified Crass position", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Subacromial-subdeltoid bursa corticosteroid injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via a {{approach}} to the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Shoulder", "condition": "Rotator cuff tendinopathy / subacromial pain", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Tendon / enthesis procedures"}}, {"form_id": "ac_joint_steroid_us", "title": "Acromioclavicular joint corticosteroid injection - ultrasound-guided", "region": "Shoulder", "family": "Small joint steroid injection", "conditions": ["AC joint osteoarthritis", "AC joint pain", "Distal clavicle degenerative pain"], "template_sheet": "ACJ_Steroid_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Sitting with arm relaxed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, short in-plane or out-of-plane approach", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Superior approach to AC joint space", "target": "AC joint capsule/joint line", "needle": "25G 1-1.5 inch needle", "injectate_product": "Physician-selected corticosteroid product - verify product and DIN", "dose_volume": "Small-joint steroid dose with local anesthetic", "diluent_anesthetic": "Small volume local anesthetic as selected", "total_volume": "Typical total 0.5-1.5 mL; verify actual"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Acromioclavicular joint corticosteroid injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via a {{approach}} to the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Small joint steroid injection", "condition_tags": "AC joint osteoarthritis; AC joint pain; Distal clavicle degenerative pain", "sheet_name": "ACJ_Steroid_US", "defaults": {"patient_position": "Sitting with arm relaxed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, short in-plane or out-of-plane approach", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Superior approach to AC joint space", "target": "AC joint capsule/joint line", "needle": "25G 1-1.5 inch needle", "injectate_product": "Physician-selected corticosteroid product - verify product and DIN", "dose_volume": "Small-joint steroid dose with local anesthetic", "diluent_anesthetic": "Small volume local anesthetic as selected", "total_volume": "Typical total 0.5-1.5 mL; verify actual", "next_procedure_medication_choice": "Physician-selected corticosteroid product - verify product and DIN", "next_procedure_dose": "Small-joint steroid dose with local anesthetic; Typical total 0.5-1.5 mL; verify actual", "next_procedure_technique": "Ultrasound-guided, short in-plane or out-of-plane approach; Superior approach to AC joint space; AC joint capsule/joint line; 25G 1-1.5 inch needle", "next_procedure_patient_position": "Sitting with arm relaxed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Acromioclavicular joint corticosteroid injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via a {{approach}} to the {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Shoulder", "condition": "Acromioclavicular joint arthropathy", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Joint injections"}}, {"form_id": "suprascapular_nerve_block_us", "title": "Suprascapular nerve block - ultrasound-guided", "region": "Shoulder", "family": "Peripheral nerve block", "conditions": ["Chronic shoulder pain", "Glenohumeral osteoarthritis pain", "Post-surgical shoulder pain where appropriate"], "template_sheet": "Suprascapular_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Sitting or prone with scapular region exposed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear or curvilinear transducer depending on depth", "approach": "Medial-to-lateral or lateral-to-medial in-plane approach", "target": "Suprascapular notch/fossa region adjacent to suprascapular nerve, avoiding vascular structures", "needle": "22G or 25G needle sized to depth", "injectate_product": "Local anesthetic +/- corticosteroid per treatment plan", "dose_volume": "Physician-selected dose/volume", "diluent_anesthetic": "Local anesthetic as selected", "total_volume": "Typical total 3-8 mL; verify actual"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Suprascapular nerve block - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, suprascapular nerve region and adjacent vessels were identified, and a {{needle}} was advanced via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Peripheral nerve block", "condition_tags": "Chronic shoulder pain; Glenohumeral osteoarthritis pain; Post-surgical shoulder pain where appropriate", "sheet_name": "Suprascapular_US", "defaults": {"patient_position": "Sitting or prone with scapular region exposed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear or curvilinear transducer depending on depth", "approach": "Medial-to-lateral or lateral-to-medial in-plane approach", "target": "Suprascapular notch/fossa region adjacent to suprascapular nerve, avoiding vascular structures", "needle": "22G or 25G needle sized to depth", "injectate_product": "Local anesthetic +/- corticosteroid per treatment plan", "dose_volume": "Physician-selected dose/volume", "diluent_anesthetic": "Local anesthetic as selected", "total_volume": "Typical total 3-8 mL; verify actual", "next_procedure_medication_choice": "Local anesthetic +/- corticosteroid per treatment plan", "next_procedure_dose": "Physician-selected dose/volume; Typical total 3-8 mL; verify actual", "next_procedure_technique": "Ultrasound-guided, in-plane; Medial-to-lateral or lateral-to-medial in-plane approach; Suprascapular notch/fossa region adjacent to suprascapular nerve, avoiding vascular structures; 22G or 25G needle sized to depth", "next_procedure_patient_position": "Sitting or prone with scapular region exposed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Suprascapular nerve block - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, suprascapular nerve region and adjacent vessels were identified, and a {{needle}} was advanced via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Shoulder", "condition": "Shoulder osteoarthritis / adhesive capsulitis; Rotator cuff tendinopathy / subacromial pain", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Block / hydrodissection", "procedure_group": "Peripheral nerve blocks"}}, {"form_id": "shoulder_tendon_prp_us", "title": "Shoulder rotator cuff / biceps tendon PRP injection - ultrasound-guided", "region": "Shoulder", "family": "PRP tendon/peritendon injection", "conditions": ["Rotator cuff tendinopathy", "Partial-thickness rotator cuff tear where appropriate", "Biceps tendinopathy"], "template_sheet": "Shoulder_PRP_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Sitting or lateral decubitus depending on tendon target", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Tendon-specific in-plane approach", "target": "Pathologic tendon/peritendinous target; avoid unnecessary intratendinous trauma unless fenestration planned", "needle": "22G or 25G needle based on tendon target", "injectate_product": "Autologous PRP prepared using clinic-selected Health Canada-compliant collection/preparation system", "dose_volume": "PRP volume per tendon target/treatment plan", "diluent_anesthetic": "Avoid injecting local anesthetic into PRP target unless deliberately selected; skin anesthesia optional", "total_volume": "Actual PRP volume injected", "prp_system": "Clinic-selected PRP kit/system - verify device/licence", "spin_protocol": "Prepare according to kit manufacturer instructions and clinic protocol"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "PRP product/preparation", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "PRP volume injected", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "PRP Preparation", "key": "prp_system", "label": "PRP system / kit", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify device/licence and clinic protocol."}, {"section": "PRP Preparation", "key": "blood_draw_volume", "label": "Blood draw volume", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual volume."}, {"section": "PRP Preparation", "key": "spin_protocol", "label": "Spin protocol / processing details", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Procedure-specific default, edit per actual kit/protocol."}, {"section": "Technique", "key": "fenestration_pattern", "label": "Fenestration/peppering pattern if performed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only actual technique."}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Shoulder rotator cuff / biceps tendon PRP injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: 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}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nPRP preparation: System: {{prp_system}}. Blood draw volume: {{blood_draw_volume}}. Spin protocol: {{spin_protocol}}. Fenestration: {{fenestration_pattern}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "PRP tendon/peritendon injection", "condition_tags": "Rotator cuff tendinopathy; Partial-thickness rotator cuff tear where appropriate; Biceps tendinopathy", "sheet_name": "Shoulder_PRP_US", "defaults": {"patient_position": "Sitting or lateral decubitus depending on tendon target", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Tendon-specific in-plane approach", "target": "Pathologic tendon/peritendinous target; avoid unnecessary intratendinous trauma unless fenestration planned", "needle": "22G or 25G needle based on tendon target", "injectate_product": "Autologous PRP prepared using clinic-selected Health Canada-compliant collection/preparation system", "dose_volume": "PRP volume per tendon target/treatment plan", "diluent_anesthetic": "Avoid injecting local anesthetic into PRP target unless deliberately selected; skin anesthesia optional", "total_volume": "Actual PRP volume injected", "prp_system": "Clinic-selected PRP kit/system - verify device/licence", "spin_protocol": "Prepare according to kit manufacturer instructions and clinic protocol", "next_procedure_medication_choice": "Autologous PRP prepared using clinic-selected Health Canada-compliant collection/preparation system", "next_procedure_dose": "PRP volume per tendon target/treatment plan; Actual PRP volume injected", "next_procedure_technique": "Ultrasound-guided, in-plane; Tendon-specific in-plane approach; Pathologic tendon/peritendinous target; avoid unnecessary intratendinous trauma unless fenestration planned; 22G or 25G needle based on tendon target", "next_procedure_patient_position": "Sitting or lateral decubitus depending on tendon target", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Shoulder rotator cuff / biceps tendon PRP injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: 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}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nPRP preparation: System: {{prp_system}}. Blood draw volume: {{blood_draw_volume}}. Spin protocol: {{spin_protocol}}. Fenestration: {{fenestration_pattern}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Shoulder", "condition": "Rotator cuff tendinopathy / subacromial pain; Long head biceps tendinopathy", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regenerative / viscosupplementation", "procedure_group": "Tendon / enthesis procedures"}}, {"form_id": "elbow_lateral_epicondyle_prp_us", "title": "Lateral epicondyle PRP injection / tendon fenestration - ultrasound-guided", "region": "Elbow", "family": "PRP tendon/peritendon injection", "conditions": ["Lateral epicondylalgia", "Common extensor tendinopathy"], "template_sheet": "LatEpic_PRP_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Sitting or supine with elbow flexed/pronated and lateral elbow exposed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Long-axis in-plane approach to common extensor origin", "target": "Common extensor tendon origin/pathologic hypoechoic tendon region", "needle": "22G or 25G needle", "injectate_product": "Autologous PRP prepared using clinic-selected Health Canada-compliant collection/preparation system", "dose_volume": "PRP volume per treatment plan", "diluent_anesthetic": "Avoid local anesthetic in tendon target unless deliberately selected; skin anesthesia optional", "total_volume": "Actual PRP volume injected", "prp_system": "Clinic-selected PRP kit/system - verify device/licence", "spin_protocol": "Prepare according to kit manufacturer instructions and clinic protocol"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "PRP product/preparation", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "PRP volume injected", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "PRP Preparation", "key": "prp_system", "label": "PRP system / kit", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify device/licence and clinic protocol."}, {"section": "PRP Preparation", "key": "blood_draw_volume", "label": "Blood draw volume", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual volume."}, {"section": "PRP Preparation", "key": "spin_protocol", "label": "Spin protocol / processing details", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Procedure-specific default, edit per actual kit/protocol."}, {"section": "Technique", "key": "fenestration_pattern", "label": "Fenestration/peppering pattern if performed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only actual technique."}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Lateral epicondyle PRP injection / tendon fenestration - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Autologous PRP was prepared. Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via {{approach}} to {{target}} with fenestration pattern as documented. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nPRP preparation: System: {{prp_system}}. Blood draw volume: {{blood_draw_volume}}. Spin protocol: {{spin_protocol}}. Fenestration: {{fenestration_pattern}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "PRP tendon/peritendon injection", "condition_tags": "Lateral epicondylalgia; Common extensor tendinopathy", "sheet_name": "LatEpic_PRP_US", "defaults": {"patient_position": "Sitting or supine with elbow flexed/pronated and lateral elbow exposed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Long-axis in-plane approach to common extensor origin", "target": "Common extensor tendon origin/pathologic hypoechoic tendon region", "needle": "22G or 25G needle", "injectate_product": "Autologous PRP prepared using clinic-selected Health Canada-compliant collection/preparation system", "dose_volume": "PRP volume per treatment plan", "diluent_anesthetic": "Avoid local anesthetic in tendon target unless deliberately selected; skin anesthesia optional", "total_volume": "Actual PRP volume injected", "prp_system": "Clinic-selected PRP kit/system - verify device/licence", "spin_protocol": "Prepare according to kit manufacturer instructions and clinic protocol", "next_procedure_medication_choice": "Autologous PRP prepared using clinic-selected Health Canada-compliant collection/preparation system", "next_procedure_dose": "PRP volume per treatment plan; Actual PRP volume injected", "next_procedure_technique": "Ultrasound-guided, in-plane; Long-axis in-plane approach to common extensor origin; Common extensor tendon origin/pathologic hypoechoic tendon region; 22G or 25G needle", "next_procedure_patient_position": "Sitting or supine with elbow flexed/pronated and lateral elbow exposed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Lateral epicondyle PRP injection / tendon fenestration - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Autologous PRP was prepared. Using {{guidance}} with a {{transducer}}, a {{needle}} was advanced via {{approach}} to {{target}} with fenestration pattern as documented. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nPRP preparation: System: {{prp_system}}. Blood draw volume: {{blood_draw_volume}}. Spin protocol: {{spin_protocol}}. Fenestration: {{fenestration_pattern}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Elbow", "condition": "Lateral epicondylalgia", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regenerative / viscosupplementation", "procedure_group": "Tendon / enthesis procedures"}}, {"form_id": "elbow_lateral_epicondyle_prolo_us", "title": "Lateral epicondyle prolotherapy - ultrasound-guided", "region": "Elbow", "family": "Prolotherapy", "conditions": ["Lateral epicondylalgia", "Common extensor tendinopathy with ligament/enthesis pain"], "template_sheet": "LatEpic_Prolo_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Sitting or supine with elbow flexed/pronated and lateral elbow exposed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided where indicated plus palpation-guided enthesis targeting as appropriate", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Site-specific approach to common extensor origin/lateral collateral ligament region", "target": "Tender enthesis/peri-ligamentous attachment at lateral epicondyle; avoid radial nerve region", "needle": "25G needle", "injectate_product": "Dextrose-based prolotherapy solution prepared per clinic protocol", "dose_volume": "Small aliquots per enthesis/site", "diluent_anesthetic": "Physician-selected diluent/local anesthetic if used", "total_volume": "Actual total volume across all sites"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Prolotherapy solution", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Concentration and aliquot volumes", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Technique", "key": "sites_treated", "label": "Exact sites treated", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only. List each site/enthesis."}, {"section": "Technique", "key": "number_of_needle_placements", "label": "Number of needle placements", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual count."}, {"section": "Technique", "key": "neurovascular_avoidance", "label": "Neurovascular structures identified/avoided", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only safety documentation."}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Lateral epicondyle prolotherapy - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}}, a {{needle}} was used via {{approach}} to treat {{sites_treated}} targeting {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nSites/count: Sites treated: {{sites_treated}}. Needle placements: {{number_of_needle_placements}}. Neurovascular safety: {{neurovascular_avoidance}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Prolotherapy", "condition_tags": "Lateral epicondylalgia; Common extensor tendinopathy with ligament/enthesis pain", "sheet_name": "LatEpic_Prolo_US", "defaults": {"patient_position": "Sitting or supine with elbow flexed/pronated and lateral elbow exposed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided where indicated plus palpation-guided enthesis targeting as appropriate", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Site-specific approach to common extensor origin/lateral collateral ligament region", "target": "Tender enthesis/peri-ligamentous attachment at lateral epicondyle; avoid radial nerve region", "needle": "25G needle", "injectate_product": "Dextrose-based prolotherapy solution prepared per clinic protocol", "dose_volume": "Small aliquots per enthesis/site", "diluent_anesthetic": "Physician-selected diluent/local anesthetic if used", "total_volume": "Actual total volume across all sites", "next_procedure_medication_choice": "Dextrose-based prolotherapy solution prepared per clinic protocol", "next_procedure_dose": "Small aliquots per enthesis/site; Actual total volume across all sites", "next_procedure_technique": "Ultrasound-guided where indicated plus palpation-guided enthesis targeting as appropriate; Site-specific approach to common extensor origin/lateral collateral ligament region; Tender enthesis/peri-ligamentous attachment at lateral epicondyle; avoid radial nerve region; 25G needle", "next_procedure_patient_position": "Sitting or supine with elbow flexed/pronated and lateral elbow exposed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Lateral epicondyle prolotherapy - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}}, a {{needle}} was used via {{approach}} to treat {{sites_treated}} targeting {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nSites/count: Sites treated: {{sites_treated}}. Needle placements: {{number_of_needle_placements}}. Neurovascular safety: {{neurovascular_avoidance}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Elbow", "condition": "Lateral epicondylalgia", "guidance_options": ["Ultrasound-guided", "Landmark-guided"], "intervention_type": "Regenerative / viscosupplementation", "procedure_group": "Epidural steroid injections (ESI)"}}, {"form_id": "first_cmc_steroid_us", "title": "First carpometacarpal joint corticosteroid injection - ultrasound-guided", "region": "Wrist / hand", "family": "Small joint steroid injection", "conditions": ["Thumb CMC osteoarthritis", "Basal joint pain"], "template_sheet": "FirstCMC_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Sitting with hand supported, thumb CMC exposed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane or out-of-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear/hockey-stick transducer if available", "approach": "Radial or dorsal approach to first CMC joint line", "target": "First CMC joint space/capsular recess", "needle": "25G or 27G 1-inch needle", "injectate_product": "Physician-selected corticosteroid product - verify product and DIN", "dose_volume": "Small-joint steroid dose with local anesthetic", "diluent_anesthetic": "Small volume local anesthetic as selected", "total_volume": "Typical total 0.5-1.0 mL; verify actual"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "First carpometacarpal joint corticosteroid injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: 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}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Small joint steroid injection", "condition_tags": "Thumb CMC osteoarthritis; Basal joint pain", "sheet_name": "FirstCMC_US", "defaults": {"patient_position": "Sitting with hand supported, thumb CMC exposed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane or out-of-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear/hockey-stick transducer if available", "approach": "Radial or dorsal approach to first CMC joint line", "target": "First CMC joint space/capsular recess", "needle": "25G or 27G 1-inch needle", "injectate_product": "Physician-selected corticosteroid product - verify product and DIN", "dose_volume": "Small-joint steroid dose with local anesthetic", "diluent_anesthetic": "Small volume local anesthetic as selected", "total_volume": "Typical total 0.5-1.0 mL; verify actual", "next_procedure_medication_choice": "Physician-selected corticosteroid product - verify product and DIN", "next_procedure_dose": "Small-joint steroid dose with local anesthetic; Typical total 0.5-1.0 mL; verify actual", "next_procedure_technique": "Ultrasound-guided, in-plane or out-of-plane; Radial or dorsal approach to first CMC joint line; First CMC joint space/capsular recess; 25G or 27G 1-inch needle", "next_procedure_patient_position": "Sitting with hand supported, thumb CMC exposed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "First carpometacarpal joint corticosteroid injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: 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}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Wrist / hand", "condition": "Thumb CMC osteoarthritis", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Joint injections"}}, {"form_id": "median_nerve_hydrodissection_us", "title": "Median nerve hydrodissection at carpal tunnel - ultrasound-guided", "region": "Wrist / hand", "family": "Hydrodissection", "conditions": ["Carpal tunnel syndrome", "Median nerve entrapment symptoms"], "template_sheet": "MedianHydro_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Supine or sitting with wrist supinated and supported", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Ulnar-to-radial or radial-to-ulnar in-plane approach according to anatomy", "target": "Perineural plane around median nerve within carpal tunnel; avoid intraneural injection", "needle": "25G 1.5-inch needle", "injectate_product": "Hydrodissection injectate per clinic protocol (e.g., saline/local anesthetic +/- steroid if selected)", "dose_volume": "Physician-selected hydrodissection volume", "diluent_anesthetic": "Local anesthetic/saline/dextrose solution as selected", "total_volume": "Typical total 5-10 mL; verify actual"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Safety", "key": "nerve_integrity_check", "label": "Intraneural injection avoided / nerve integrity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only safety statement.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Technique", "key": "hydrodissection_plane", "label": "Hydrodissection/perineural spread plane", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread."}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Median nerve hydrodissection at carpal tunnel - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, the median nerve, flexor tendons, and vascular structures were identified. A {{needle}} was advanced via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Hydrodissection", "condition_tags": "Carpal tunnel syndrome; Median nerve entrapment symptoms", "sheet_name": "MedianHydro_US", "defaults": {"patient_position": "Supine or sitting with wrist supinated and supported", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Ulnar-to-radial or radial-to-ulnar in-plane approach according to anatomy", "target": "Perineural plane around median nerve within carpal tunnel; avoid intraneural injection", "needle": "25G 1.5-inch needle", "injectate_product": "Hydrodissection injectate per clinic protocol (e.g., saline/local anesthetic +/- steroid if selected)", "dose_volume": "Physician-selected hydrodissection volume", "diluent_anesthetic": "Local anesthetic/saline/dextrose solution as selected", "total_volume": "Typical total 5-10 mL; verify actual", "next_procedure_medication_choice": "Hydrodissection injectate per clinic protocol (e.g., saline/local anesthetic +/- steroid if selected)", "next_procedure_dose": "Physician-selected hydrodissection volume; Typical total 5-10 mL; verify actual", "next_procedure_technique": "Ultrasound-guided, in-plane; Ulnar-to-radial or radial-to-ulnar in-plane approach according to anatomy; Perineural plane around median nerve within carpal tunnel; avoid intraneural injection; 25G 1.5-inch needle", "next_procedure_patient_position": "Supine or sitting with wrist supinated and supported", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Median nerve hydrodissection at carpal tunnel - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, the median nerve, flexor tendons, and vascular structures were identified. A {{needle}} was advanced via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Wrist / hand", "condition": "Carpal tunnel syndrome", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Block / hydrodissection", "procedure_group": "Peripheral nerve blocks"}}, {"form_id": "carpal_tunnel_steroid_us", "title": "Carpal tunnel corticosteroid injection - ultrasound-guided", "region": "Wrist / hand", "family": "Peripheral nerve region steroid injection", "conditions": ["Carpal tunnel syndrome", "Median nerve entrapment pain"], "template_sheet": "CarpalTunnel_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Supine or sitting with wrist supinated and supported", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Ulnar-to-radial in-plane approach avoiding ulnar neurovascular structures", "target": "Perineural/peritendinous carpal tunnel plane adjacent to median nerve; avoid intraneural injection", "needle": "25G 1.5-inch needle", "injectate_product": "Physician-selected corticosteroid product - verify product and DIN", "dose_volume": "Small dose steroid with local anesthetic/saline per treatment plan", "diluent_anesthetic": "Local anesthetic/saline as selected", "total_volume": "Typical total 1-3 mL; verify actual"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Safety", "key": "nerve_integrity_check", "label": "Intraneural injection avoided / nerve integrity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only safety statement.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Technique", "key": "hydrodissection_plane", "label": "Hydrodissection/perineural spread plane", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread."}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Carpal tunnel corticosteroid injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, the median nerve and surrounding tendons/vessels were identified. A {{needle}} was advanced via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Peripheral nerve region steroid injection", "condition_tags": "Carpal tunnel syndrome; Median nerve entrapment pain", "sheet_name": "CarpalTunnel_US", "defaults": {"patient_position": "Supine or sitting with wrist supinated and supported", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Ulnar-to-radial in-plane approach avoiding ulnar neurovascular structures", "target": "Perineural/peritendinous carpal tunnel plane adjacent to median nerve; avoid intraneural injection", "needle": "25G 1.5-inch needle", "injectate_product": "Physician-selected corticosteroid product - verify product and DIN", "dose_volume": "Small dose steroid with local anesthetic/saline per treatment plan", "diluent_anesthetic": "Local anesthetic/saline as selected", "total_volume": "Typical total 1-3 mL; verify actual", "next_procedure_medication_choice": "Physician-selected corticosteroid product - verify product and DIN", "next_procedure_dose": "Small dose steroid with local anesthetic/saline per treatment plan; Typical total 1-3 mL; verify actual", "next_procedure_technique": "Ultrasound-guided, in-plane; Ulnar-to-radial in-plane approach avoiding ulnar neurovascular structures; Perineural/peritendinous carpal tunnel plane adjacent to median nerve; avoid intraneural injection; 25G 1.5-inch needle", "next_procedure_patient_position": "Supine or sitting with wrist supinated and supported", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Carpal tunnel corticosteroid injection - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, the median nerve and surrounding tendons/vessels were identified. A {{needle}} was advanced via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Wrist / hand", "condition": "Carpal tunnel syndrome", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Office-based pain procedure"}}, {"form_id": "occipital_nerve_block_us", "title": "Greater/lesser occipital nerve block - ultrasound-guided or landmark-guided", "region": "Head / neck", "family": "Peripheral nerve block", "conditions": ["Occipital neuralgia", "Cervicogenic headache", "Chronic migraine with occipital tenderness"], "template_sheet": "Occipital_Block", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Sitting or prone with upper cervical/occipital region exposed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided where indicated or landmark-guided superficial block according to anatomy and risk", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer if ultrasound-guided", "approach": "Medial-to-lateral or lateral-to-medial approach near occipital nerve target", "target": "Greater occipital nerve region at C2/obliquus capitis inferior plane or distal occipital tenderness point; lesser occipital nerve if indicated", "needle": "25G needle", "injectate_product": "Local anesthetic +/- corticosteroid per treatment plan", "dose_volume": "Physician-selected dose/volume per nerve/site", "diluent_anesthetic": "Local anesthetic as selected", "total_volume": "Actual total volume across sites"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Greater/lesser occipital nerve block - ultrasound-guided or landmark-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}}, the {{needle}} was advanced via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Peripheral nerve block", "condition_tags": "Occipital neuralgia; Cervicogenic headache; Chronic migraine with occipital tenderness", "sheet_name": "Occipital_Block", "defaults": {"patient_position": "Sitting or prone with upper cervical/occipital region exposed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided where indicated or landmark-guided superficial block according to anatomy and risk", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer if ultrasound-guided", "approach": "Medial-to-lateral or lateral-to-medial approach near occipital nerve target", "target": "Greater occipital nerve region at C2/obliquus capitis inferior plane or distal occipital tenderness point; lesser occipital nerve if indicated", "needle": "25G needle", "injectate_product": "Local anesthetic +/- corticosteroid per treatment plan", "dose_volume": "Physician-selected dose/volume per nerve/site", "diluent_anesthetic": "Local anesthetic as selected", "total_volume": "Actual total volume across sites", "next_procedure_medication_choice": "Local anesthetic +/- corticosteroid per treatment plan", "next_procedure_dose": "Physician-selected dose/volume per nerve/site; Actual total volume across sites", "next_procedure_technique": "Ultrasound-guided where indicated or landmark-guided superficial block according to anatomy and risk; Medial-to-lateral or lateral-to-medial approach near occipital nerve target; Greater occipital nerve region at C2/obliquus capitis inferior plane or distal occipital tenderness point; lesser occipital nerve if indicated; 25G needle", "next_procedure_patient_position": "Sitting or prone with upper cervical/occipital region exposed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Greater/lesser occipital nerve block - ultrasound-guided or landmark-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}}, the {{needle}} was advanced via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Cervical spine / head", "condition": "Occipital neuralgia / cervicogenic headache", "guidance_options": ["Ultrasound-guided", "Landmark-guided"], "intervention_type": "Block / hydrodissection", "procedure_group": "Peripheral nerve blocks"}}, {"form_id": "trigger_point_injections", "title": "Trigger point injections - ultrasound-guided or landmark-guided", "region": "Myofascial", "family": "Trigger point injection", "conditions": ["Myofascial pain syndrome", "Neck/back myofascial pain", "Fibromyalgia-associated focal trigger points where appropriate"], "template_sheet": "Trigger_Points", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Positioned to expose and relax target muscles", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided for deep/high-risk muscles; landmark-guided for superficial trigger points as appropriate", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer if ultrasound-guided", "approach": "Site-specific direct approach into trigger point while avoiding pleura/neurovascular structures", "target": "Palpable trigger points / sonographically identified myofascial targets", "needle": "25G needle; longer needle for deep muscles if required", "injectate_product": "Local anesthetic or dry needling per treatment plan; steroid not routine unless specifically selected", "dose_volume": "Small aliquots per trigger point", "diluent_anesthetic": "Local anesthetic as selected if wet needling", "total_volume": "Actual total volume across all points"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Technique", "key": "sites_treated", "label": "Muscles / trigger points treated", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only exact muscles/points."}, {"section": "Technique", "key": "number_of_needle_placements", "label": "Number of trigger points / needle placements", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual count."}, {"section": "Technique", "key": "dry_or_wet_needling", "label": "Dry needling vs injectate technique", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Dry needling;Wet needling;Combined", "help": "Manual-only technique used."}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Trigger point injections - ultrasound-guided or landmark-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Trigger points were identified in {{sites_treated}}. Using {{guidance}}, a {{needle}} was directed via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Trigger point injection", "condition_tags": "Myofascial pain syndrome; Neck/back myofascial pain; Fibromyalgia-associated focal trigger points where appropriate", "sheet_name": "Trigger_Points", "defaults": {"patient_position": "Positioned to expose and relax target muscles", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided for deep/high-risk muscles; landmark-guided for superficial trigger points as appropriate", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer if ultrasound-guided", "approach": "Site-specific direct approach into trigger point while avoiding pleura/neurovascular structures", "target": "Palpable trigger points / sonographically identified myofascial targets", "needle": "25G needle; longer needle for deep muscles if required", "injectate_product": "Local anesthetic or dry needling per treatment plan; steroid not routine unless specifically selected", "dose_volume": "Small aliquots per trigger point", "diluent_anesthetic": "Local anesthetic as selected if wet needling", "total_volume": "Actual total volume across all points", "next_procedure_medication_choice": "Local anesthetic or dry needling per treatment plan; steroid not routine unless specifically selected", "next_procedure_dose": "Small aliquots per trigger point; Actual total volume across all points", "next_procedure_technique": "Ultrasound-guided for deep/high-risk muscles; landmark-guided for superficial trigger points as appropriate; Site-specific direct approach into trigger point while avoiding pleura/neurovascular structures; Palpable trigger points / sonographically identified myofascial targets; 25G needle; longer needle for deep muscles if required", "next_procedure_patient_position": "Positioned to expose and relax target muscles", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Trigger point injections - ultrasound-guided or landmark-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Trigger points were identified in {{sites_treated}}. Using {{guidance}}, a {{needle}} was directed via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "General / multisite pain", "condition": "Myofascial pain syndrome; Peripheral neuropathic pain / post-herpetic neuralgia; Fibromyalgia / central sensitization; Chronic post-surgical pain; Vertebrogenic low back pain / Modic change-associated pain; Flank pain / thoracolumbar regional pain", "guidance_options": ["Ultrasound-guided", "Landmark-guided"], "intervention_type": "Injection", "procedure_group": "Tendon / enthesis procedures"}}, {"form_id": "cervical_mbb", "title": "Cervical medial branch diagnostic block - image-guided", "region": "Cervical spine", "family": "Diagnostic medial branch block", "conditions": ["Cervical facet-mediated pain", "Cervicogenic neck pain", "Whiplash-associated chronic neck pain after assessment"], "template_sheet": "Cervical_MBB", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Prone or lateral position according to imaging modality and target levels", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Image-guided; fluoroscopy preferred for bony target confirmation unless ultrasound protocol is used within scope", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "transducer": "Ultrasound transducer if ultrasound-guided; fluoroscope if fluoroscopy-guided", "approach": "Level-specific approach to cervical medial branch target", "target": "Cervical medial branch targets at documented levels", "needle": "25G spinal needle or needle sized to target depth", "injectate_product": "Local anesthetic diagnostic block injectate", "dose_volume": "Low-volume local anesthetic per target", "diluent_anesthetic": "Local anesthetic selected for diagnostic plan", "total_volume": "Actual total volume across levels", "post_block_diary_instructions": "Patient instructed to document pain relief percentage, duration, functional change, and analgesic use after diagnostic block."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from fluoroscopy_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Diagnostic block injectate", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Volume per target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Technique", "key": "levels_targets", "label": "Levels / nerves targeted", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only exact target levels.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Diagnostic", "key": "baseline_pain_score", "label": "Baseline pain score and provocative movement", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only diagnostic baseline."}, {"section": "Diagnostic", "key": "post_block_diary_instructions", "label": "Pain diary / diagnostic response instructions", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Procedure-specific diagnostic instructions."}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Cervical medial branch diagnostic block - image-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}}, a {{needle}} was advanced via {{approach}} to {{target}} at the documented levels. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nDiagnostic details: Targets: {{levels_targets}}. Baseline: {{baseline_pain_score}}. Pain diary instructions: {{post_block_diary_instructions}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Diagnostic medial branch block", "condition_tags": "Cervical facet-mediated pain; Cervicogenic neck pain; Whiplash-associated chronic neck pain after assessment", "sheet_name": "Cervical_MBB", "defaults": {"patient_position": "Prone or lateral position according to imaging modality and target levels", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Image-guided; fluoroscopy preferred for bony target confirmation unless ultrasound protocol is used within scope", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "transducer": "Ultrasound transducer if ultrasound-guided; fluoroscope if fluoroscopy-guided", "approach": "Level-specific approach to cervical medial branch target", "target": "Cervical medial branch targets at documented levels", "needle": "25G spinal needle or needle sized to target depth", "injectate_product": "Local anesthetic diagnostic block injectate", "dose_volume": "Low-volume local anesthetic per target", "diluent_anesthetic": "Local anesthetic selected for diagnostic plan", "total_volume": "Actual total volume across levels", "post_block_diary_instructions": "Patient instructed to document pain relief percentage, duration, functional change, and analgesic use after diagnostic block.", "next_procedure_medication_choice": "Local anesthetic diagnostic block injectate", "next_procedure_dose": "Low-volume local anesthetic per target; Actual total volume across levels", "next_procedure_technique": "Image-guided; fluoroscopy preferred for bony target confirmation unless ultrasound protocol is used within scope; Level-specific approach to cervical medial branch target; Cervical medial branch targets at documented levels; 25G spinal needle or needle sized to target depth", "next_procedure_patient_position": "Prone or lateral position according to imaging modality and target levels", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Cervical medial branch diagnostic block - image-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}}, a {{needle}} was advanced via {{approach}} to {{target}} at the documented levels. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nDiagnostic details: Targets: {{levels_targets}}. Baseline: {{baseline_pain_score}}. Pain diary instructions: {{post_block_diary_instructions}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Cervical spine / head", "condition": "Cervical facet-mediated pain; Occipital neuralgia / cervicogenic headache", "guidance_options": ["Ultrasound-guided", "Fluoroscopy-guided"], "intervention_type": "Block / hydrodissection", "procedure_group": "Facet / medial branch procedures"}}, {"form_id": "lumbar_mbb", "title": "Lumbar medial branch diagnostic block - image-guided", "region": "Lumbar spine", "family": "Diagnostic medial branch block", "conditions": ["Lumbar facet-mediated pain", "Chronic axial low back pain", "Post-traumatic or degenerative lumbar facet pain"], "template_sheet": "Lumbar_MBB", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Prone with abdomen supported as needed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Image-guided; fluoroscopy preferred for bony target confirmation unless ultrasound protocol is used within scope", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "transducer": "Ultrasound transducer if ultrasound-guided; fluoroscope if fluoroscopy-guided", "approach": "Posterior oblique/level-specific approach", "target": "Lumbar medial branch targets at junction of transverse process and superior articular process, or L5 dorsal ramus target as documented", "needle": "25G spinal needle or needle sized to target depth", "injectate_product": "Local anesthetic diagnostic block injectate", "dose_volume": "Low-volume local anesthetic per target", "diluent_anesthetic": "Local anesthetic selected for diagnostic plan", "total_volume": "Actual total volume across levels", "post_block_diary_instructions": "Patient instructed to document pain relief percentage, duration, functional change, and analgesic use after diagnostic block."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from fluoroscopy_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Diagnostic block injectate", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Volume per target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Technique", "key": "levels_targets", "label": "Levels / nerves targeted", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only exact target levels.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Diagnostic", "key": "baseline_pain_score", "label": "Baseline pain score and provocative movement", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only diagnostic baseline."}, {"section": "Diagnostic", "key": "post_block_diary_instructions", "label": "Pain diary / diagnostic response instructions", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Procedure-specific diagnostic instructions."}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Lumbar medial branch diagnostic block - image-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}}, a {{needle}} was advanced via {{approach}} to {{target}} at the documented levels. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nDiagnostic details: Targets: {{levels_targets}}. Baseline: {{baseline_pain_score}}. Pain diary instructions: {{post_block_diary_instructions}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Diagnostic medial branch block", "condition_tags": "Lumbar facet-mediated pain; Chronic axial low back pain; Post-traumatic or degenerative lumbar facet pain", "sheet_name": "Lumbar_MBB", "defaults": {"patient_position": "Prone with abdomen supported as needed", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Image-guided; fluoroscopy preferred for bony target confirmation unless ultrasound protocol is used within scope", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "transducer": "Ultrasound transducer if ultrasound-guided; fluoroscope if fluoroscopy-guided", "approach": "Posterior oblique/level-specific approach", "target": "Lumbar medial branch targets at junction of transverse process and superior articular process, or L5 dorsal ramus target as documented", "needle": "25G spinal needle or needle sized to target depth", "injectate_product": "Local anesthetic diagnostic block injectate", "dose_volume": "Low-volume local anesthetic per target", "diluent_anesthetic": "Local anesthetic selected for diagnostic plan", "total_volume": "Actual total volume across levels", "post_block_diary_instructions": "Patient instructed to document pain relief percentage, duration, functional change, and analgesic use after diagnostic block.", "next_procedure_medication_choice": "Local anesthetic diagnostic block injectate", "next_procedure_dose": "Low-volume local anesthetic per target; Actual total volume across levels", "next_procedure_technique": "Image-guided; fluoroscopy preferred for bony target confirmation unless ultrasound protocol is used within scope; Posterior oblique/level-specific approach; Lumbar medial branch targets at junction of transverse process and superior articular process, or L5 dorsal ramus target as documented; 25G spinal needle or needle sized to target depth", "next_procedure_patient_position": "Prone with abdomen supported as needed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Lumbar medial branch diagnostic block - image-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}}, a {{needle}} was advanced via {{approach}} to {{target}} at the documented levels. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nDiagnostic details: Targets: {{levels_targets}}. Baseline: {{baseline_pain_score}}. Pain diary instructions: {{post_block_diary_instructions}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Lumbar spine", "condition": "Lumbar facet-mediated pain", "guidance_options": ["Ultrasound-guided", "Fluoroscopy-guided"], "intervention_type": "Block / hydrodissection", "procedure_group": "Facet / medial branch procedures"}}, {"form_id": "lumbar_medial_branch_rfa", "title": "Lumbar medial branch radiofrequency ablation", "region": "Lumbar spine", "family": "Radiofrequency ablation", "conditions": ["Lumbar facet-mediated pain after positive diagnostic blocks", "Chronic axial low back pain"], "template_sheet": "Lumbar_MBRFA", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Prone with abdomen supported as needed", "monitoring": "Non-invasive monitoring was used as clinically indicated. The patient remained communicative during stimulation and lesioning unless otherwise documented.", "guidance": "Fluoroscopy-guided or other approved image guidance according to clinic protocol", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "imaging_modality": "Fluoroscopy", "cannula": "RF cannula sized to target depth with selected active tip", "generator": "Clinic RF generator - verify device and settings", "electrode_orientation": "Cannula positioned parallel to target medial branch course where feasible; L5 dorsal ramus targeted as documented", "lesion_settings": "Conventional RF settings per clinic protocol; document actual temperature/time", "post_lesion_injectate": "Small volume local anesthetic +/- steroid if selected and appropriate"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from fluoroscopy_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Lumbar medial branch radiofrequency ablation\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: None Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Radiofrequency ablation", "condition_tags": "Lumbar facet-mediated pain after positive diagnostic blocks; Chronic axial low back pain", "sheet_name": "Lumbar_MBRFA", "defaults": {"patient_position": "Prone with abdomen supported as needed", "monitoring": "Non-invasive monitoring was used as clinically indicated. The patient remained communicative during stimulation and lesioning unless otherwise documented.", "guidance": "Fluoroscopy-guided or other approved image guidance according to clinic protocol", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "imaging_modality": "Fluoroscopy", "cannula": "RF cannula sized to target depth with selected active tip", "generator": "Clinic RF generator - verify device and settings", "electrode_orientation": "Cannula positioned parallel to target medial branch course where feasible; L5 dorsal ramus targeted as documented", "lesion_settings": "Conventional RF settings per clinic protocol; document actual temperature/time", "post_lesion_injectate": "Small volume local anesthetic +/- steroid if selected and appropriate", "next_procedure_medication_choice": "Small volume local anesthetic +/- steroid if selected and appropriate", "next_procedure_dose": "Conventional RF settings per clinic protocol; document actual temperature/time", "next_procedure_technique": "Fluoroscopy-guided or other approved image guidance according to clinic protocol; RF cannula sized to target depth with selected active tip", "next_procedure_patient_position": "Prone with abdomen supported as needed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating nerve ablation/RFA, usual interval is about every year or longer unless physician documents a different rationale; reassess indication, diagnostic response, neurologic status, and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Lumbar medial branch radiofrequency ablation\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: None Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Lumbar spine", "condition": "Lumbar facet-mediated pain", "guidance_options": ["Fluoroscopy-guided"], "intervention_type": "Ablation / PRF", "procedure_group": "Facet / medial branch procedures"}}, {"form_id": "cervical_medial_branch_rfa", "title": "Cervical medial branch radiofrequency ablation", "region": "Cervical spine", "family": "Radiofrequency ablation", "conditions": ["Cervical facet-mediated pain after positive diagnostic blocks", "Cervicogenic neck pain"], "template_sheet": "Cervical_MBRFA", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Prone, lateral, or oblique positioning according to target and imaging protocol", "monitoring": "Non-invasive monitoring was used as clinically indicated. The patient remained communicative during stimulation and lesioning unless otherwise documented.", "guidance": "Fluoroscopy-guided or other approved image guidance according to clinic protocol", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "imaging_modality": "Fluoroscopy", "cannula": "RF cannula sized to cervical target depth with selected active tip", "generator": "Clinic RF generator - verify device and settings", "electrode_orientation": "Cannula positioned along target articular pillar/medial branch target according to level and safety anatomy", "lesion_settings": "Conventional RF settings per clinic protocol; document actual temperature/time", "post_lesion_injectate": "Small volume local anesthetic +/- steroid if selected and appropriate"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from fluoroscopy_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Cervical medial branch radiofrequency ablation\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: None Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Radiofrequency ablation", "condition_tags": "Cervical facet-mediated pain after positive diagnostic blocks; Cervicogenic neck pain", "sheet_name": "Cervical_MBRFA", "defaults": {"patient_position": "Prone, lateral, or oblique positioning according to target and imaging protocol", "monitoring": "Non-invasive monitoring was used as clinically indicated. The patient remained communicative during stimulation and lesioning unless otherwise documented.", "guidance": "Fluoroscopy-guided or other approved image guidance according to clinic protocol", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "imaging_modality": "Fluoroscopy", "cannula": "RF cannula sized to cervical target depth with selected active tip", "generator": "Clinic RF generator - verify device and settings", "electrode_orientation": "Cannula positioned along target articular pillar/medial branch target according to level and safety anatomy", "lesion_settings": "Conventional RF settings per clinic protocol; document actual temperature/time", "post_lesion_injectate": "Small volume local anesthetic +/- steroid if selected and appropriate", "next_procedure_medication_choice": "Small volume local anesthetic +/- steroid if selected and appropriate", "next_procedure_dose": "Conventional RF settings per clinic protocol; document actual temperature/time", "next_procedure_technique": "Fluoroscopy-guided or other approved image guidance according to clinic protocol; RF cannula sized to cervical target depth with selected active tip", "next_procedure_patient_position": "Prone, lateral, or oblique positioning according to target and imaging protocol", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating nerve ablation/RFA, usual interval is about every year or longer unless physician documents a different rationale; reassess indication, diagnostic response, neurologic status, and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Cervical medial branch radiofrequency ablation\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: None Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Cervical spine / head", "condition": "Cervical facet-mediated pain", "guidance_options": ["Fluoroscopy-guided"], "intervention_type": "Ablation / PRF", "procedure_group": "Facet / medial branch procedures"}}, {"form_id": "caudal_esi_fluoro", "title": "Caudal epidural steroid injection - fluoroscopy-guided", "region": "Lumbar / sacral spine", "family": "Epidural steroid injection", "conditions": ["Lumbar radicular pain", "Spinal stenosis-related leg pain", "Post-laminectomy radicular pain where appropriate"], "template_sheet": "Caudal_ESI", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Prone with sacral hiatus accessible", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Fluoroscopy-guided with contrast confirmation if not contraindicated", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "transducer": "Fluoroscope; ultrasound may assist sacral hiatus identification", "approach": "Midline caudal approach through sacral hiatus", "target": "Caudal epidural space with contrast-confirmed epidural spread", "needle": "22G spinal needle or epidural needle according to protocol", "injectate_product": "Epidural steroid injectate selected by physician; verify product, route appropriateness, and DIN", "dose_volume": "Physician-selected epidural steroid dose/volume", "diluent_anesthetic": "Preservative-free saline/local anesthetic if selected", "total_volume": "Actual epidural injectate volume"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from fluoroscopy_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Epidural/SNRB injectate", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose/volume per level", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Technique", "key": "levels_targets", "label": "Levels / nerve roots treated", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only exact levels.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "contrast_used", "label": "Contrast used and spread pattern", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual contrast/radiographic finding."}, {"section": "Safety", "key": "paresthesia_or_intravascular_check", "label": "Paresthesia/intravascular uptake check", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only safety finding.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "neurologic_status_post", "label": "Post-procedure neurologic status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual status.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Caudal epidural steroid injection - fluoroscopy-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}}, a {{needle}} was advanced via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nSpine-specific details: Levels/roots: {{levels_targets}}. Contrast/spread: {{contrast_used}}. Safety check: {{paresthesia_or_intravascular_check}}. Post-procedure neurologic status: {{neurologic_status_post}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Epidural steroid injection", "condition_tags": "Lumbar radicular pain; Spinal stenosis-related leg pain; Post-laminectomy radicular pain where appropriate", "sheet_name": "Caudal_ESI", "defaults": {"patient_position": "Prone with sacral hiatus accessible", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Fluoroscopy-guided with contrast confirmation if not contraindicated", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "transducer": "Fluoroscope; ultrasound may assist sacral hiatus identification", "approach": "Midline caudal approach through sacral hiatus", "target": "Caudal epidural space with contrast-confirmed epidural spread", "needle": "22G spinal needle or epidural needle according to protocol", "injectate_product": "Epidural steroid injectate selected by physician; verify product, route appropriateness, and DIN", "dose_volume": "Physician-selected epidural steroid dose/volume", "diluent_anesthetic": "Preservative-free saline/local anesthetic if selected", "total_volume": "Actual epidural injectate volume", "next_procedure_medication_choice": "Epidural steroid injectate selected by physician; verify product, route appropriateness, and DIN", "next_procedure_dose": "Physician-selected epidural steroid dose/volume; Actual epidural injectate volume", "next_procedure_technique": "Fluoroscopy-guided with contrast confirmation if not contraindicated; Midline caudal approach through sacral hiatus; Caudal epidural space with contrast-confirmed epidural spread; 22G spinal needle or epidural needle according to protocol", "next_procedure_patient_position": "Prone with sacral hiatus accessible", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Caudal epidural steroid injection - fluoroscopy-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}}, a {{needle}} was advanced via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nSpine-specific details: Levels/roots: {{levels_targets}}. Contrast/spread: {{contrast_used}}. Safety check: {{paresthesia_or_intravascular_check}}. Post-procedure neurologic status: {{neurologic_status_post}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Lumbar spine", "condition": "Lumbar radicular pain / sciatica; Failed back surgery syndrome / persistent spinal pain syndrome", "guidance_options": ["Fluoroscopy-guided"], "intervention_type": "Injection", "procedure_group": "Epidural steroid injections (ESI)"}}, {"form_id": "tf_snerb_esi_fluoro", "title": "Transforaminal selective nerve root / epidural steroid injection - fluoroscopy-guided", "region": "Spine", "family": "Transforaminal ESI / selective nerve root block", "conditions": ["Lumbar radicular pain", "Cervical/thoracic/lumbar nerve root pain where appropriate", "Foraminal stenosis-related radicular pain"], "template_sheet": "TF_SNRB_ESI", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Prone or oblique position according to spinal region and level", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Fluoroscopy-guided with contrast confirmation and safety imaging according to region/protocol", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "transducer": "Fluoroscope", "approach": "Level-specific transforaminal/nerve-root approach", "target": "Target neural foramen/nerve root sleeve at documented level(s)", "needle": "Spinal needle sized to level/depth", "injectate_product": "Physician-selected non-particulate or other appropriate injectate per route/risk assessment; verify product and DIN", "dose_volume": "Physician-selected dose/volume per level", "diluent_anesthetic": "Preservative-free saline/local anesthetic if selected", "total_volume": "Actual injectate volume per level"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from fluoroscopy_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Epidural/SNRB injectate", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose/volume per level", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Technique", "key": "levels_targets", "label": "Levels / nerve roots treated", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only exact levels.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "contrast_used", "label": "Contrast used and spread pattern", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual contrast/radiographic finding."}, {"section": "Safety", "key": "paresthesia_or_intravascular_check", "label": "Paresthesia/intravascular uptake check", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only safety finding.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "neurologic_status_post", "label": "Post-procedure neurologic status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual status.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Transforaminal selective nerve root / epidural steroid injection - fluoroscopy-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}}, a {{needle}} was advanced via {{approach}} to {{target}} at the documented level(s). Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nSpine-specific details: Levels/roots: {{levels_targets}}. Contrast/spread: {{contrast_used}}. Safety check: {{paresthesia_or_intravascular_check}}. Post-procedure neurologic status: {{neurologic_status_post}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Transforaminal ESI / selective nerve root block", "condition_tags": "Lumbar radicular pain; Cervical/thoracic/lumbar nerve root pain where appropriate; Foraminal stenosis-related radicular pain", "sheet_name": "TF_SNRB_ESI", "defaults": {"patient_position": "Prone or oblique position according to spinal region and level", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Fluoroscopy-guided with contrast confirmation and safety imaging according to region/protocol", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "transducer": "Fluoroscope", "approach": "Level-specific transforaminal/nerve-root approach", "target": "Target neural foramen/nerve root sleeve at documented level(s)", "needle": "Spinal needle sized to level/depth", "injectate_product": "Physician-selected non-particulate or other appropriate injectate per route/risk assessment; verify product and DIN", "dose_volume": "Physician-selected dose/volume per level", "diluent_anesthetic": "Preservative-free saline/local anesthetic if selected", "total_volume": "Actual injectate volume per level", "next_procedure_medication_choice": "Physician-selected non-particulate or other appropriate injectate per route/risk assessment; verify product and DIN", "next_procedure_dose": "Physician-selected dose/volume per level; Actual injectate volume per level", "next_procedure_technique": "Fluoroscopy-guided with contrast confirmation and safety imaging according to region/protocol; Level-specific transforaminal/nerve-root approach; Target neural foramen/nerve root sleeve at documented level(s); Spinal needle sized to level/depth", "next_procedure_patient_position": "Prone or oblique position according to spinal region and level", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Transforaminal selective nerve root / epidural steroid injection - fluoroscopy-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}}, a {{needle}} was advanced via {{approach}} to {{target}} at the documented level(s). Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nSpine-specific details: Levels/roots: {{levels_targets}}. Contrast/spread: {{contrast_used}}. Safety check: {{paresthesia_or_intravascular_check}}. Post-procedure neurologic status: {{neurologic_status_post}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Lumbar spine", "condition": "Lumbar radicular pain / sciatica", "guidance_options": ["Fluoroscopy-guided"], "intervention_type": "Block / hydrodissection", "procedure_group": "Epidural steroid injections (ESI)"}}, {"form_id": "intercostal_nerve_block_us", "title": "Intercostal nerve block - ultrasound-guided", "region": "Thoracic / chest wall", "family": "Peripheral nerve block", "conditions": ["Intercostal neuralgia", "Post-thoracotomy pain", "Rib fracture chronic pain where appropriate"], "template_sheet": "Intercostal_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Lateral decubitus, sitting, or prone according to rib level and access", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear or curvilinear transducer based on depth", "approach": "In-plane approach to rib/intercostal plane", "target": "Intercostal neurovascular bundle region at documented rib level while maintaining needle tip away from pleura", "needle": "22G or 25G needle sized to depth", "injectate_product": "Local anesthetic +/- corticosteroid per treatment plan", "dose_volume": "Physician-selected dose/volume per level", "diluent_anesthetic": "Local anesthetic as selected", "total_volume": "Actual total volume across levels"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Technique", "key": "levels_targets", "label": "Rib levels / intercostal nerves treated", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only exact levels.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Safety", "key": "pleura_visualization", "label": "Pleura visualization and avoidance", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only safety documentation.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Intercostal nerve block - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, rib, pleura, and intercostal structures were identified. A {{needle}} was advanced via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Peripheral nerve block", "condition_tags": "Intercostal neuralgia; Post-thoracotomy pain; Rib fracture chronic pain where appropriate", "sheet_name": "Intercostal_US", "defaults": {"patient_position": "Lateral decubitus, sitting, or prone according to rib level and access", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear or curvilinear transducer based on depth", "approach": "In-plane approach to rib/intercostal plane", "target": "Intercostal neurovascular bundle region at documented rib level while maintaining needle tip away from pleura", "needle": "22G or 25G needle sized to depth", "injectate_product": "Local anesthetic +/- corticosteroid per treatment plan", "dose_volume": "Physician-selected dose/volume per level", "diluent_anesthetic": "Local anesthetic as selected", "total_volume": "Actual total volume across levels", "next_procedure_medication_choice": "Local anesthetic +/- corticosteroid per treatment plan", "next_procedure_dose": "Physician-selected dose/volume per level; Actual total volume across levels", "next_procedure_technique": "Ultrasound-guided, in-plane; In-plane approach to rib/intercostal plane; Intercostal neurovascular bundle region at documented rib level while maintaining needle tip away from pleura; 22G or 25G needle sized to depth", "next_procedure_patient_position": "Lateral decubitus, sitting, or prone according to rib level and access", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Intercostal nerve block - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, rib, pleura, and intercostal structures were identified. A {{needle}} was advanced via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Thoracic spine / chest wall", "condition": "Thoracic facet / rib / chest wall pain; Intercostal neuralgia / post-thoracotomy pain; Peripheral neuropathic pain / post-herpetic neuralgia; Chronic post-surgical pain; Post-mastectomy / post-thoracotomy chest wall pain", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Block / hydrodissection", "procedure_group": "Peripheral nerve blocks"}}, {"form_id": "stellate_ganglion_block_us", "title": "Stellate ganglion block - ultrasound-guided", "region": "Cervical sympathetic", "family": "Sympathetic blocks", "conditions": ["CRPS upper limb", "Sympathetically maintained pain", "Selected neuropathic pain syndromes"], "template_sheet": "Stellate_US", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Supine with slight neck extension and head rotated away as tolerated", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane or out-of-plane according to anatomy and safety", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Lateral-to-medial or medial-to-lateral approach at C6/C7 region according to anatomy", "target": "Prevertebral fascial plane adjacent to longus colli while avoiding carotid, internal jugular, thyroid, esophagus, vertebral artery, and neuraxis", "needle": "22G or 25G echogenic needle sized to depth", "injectate_product": "Local anesthetic per sympathetic block protocol", "dose_volume": "Physician-selected low-volume incremental injection", "diluent_anesthetic": "Local anesthetic as selected", "total_volume": "Actual volume injected incrementally", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_injection."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Technique", "key": "transducer", "label": "Transducer / probe", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific if ultrasound-guided."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle type / gauge / length", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Fluid aspirated;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / resistance / spread", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default may be changed to match product selected and Health Canada verification."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default but must be verified and edited if changed."}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Diluent / local anesthetic component", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total injectate volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; verify actual total.", "quick_options": ["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."]}, {"section": "Safety", "key": "aspiration_incremental_injection", "label": "Incremental injection and aspiration checks", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only safety checks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Outcome", "key": "sympathetic_block_signs", "label": "Signs of sympathetic block", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "Horner syndrome;Warmth;Other;None observed", "help": "Manual-only actual effect.", "quick_options": ["No immediate complication observed.", "Response will be reassessed after the expected onset window."]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Stellate ganglion block - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, carotid artery, internal jugular vein, thyroid, longus colli, and surrounding structures were identified. A {{needle}} was advanced via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Sympathetic blocks", "condition_tags": "Upper limb CRPS; Sympathetically maintained pain; Facial/upper extremity neuropathic pain", "sheet_name": "Stellate_US", "defaults": {"patient_position": "Supine with slight neck extension and head rotated away as tolerated", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Ultrasound-guided, in-plane or out-of-plane according to anatomy and safety", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer": "High-frequency linear transducer", "approach": "Lateral-to-medial or medial-to-lateral approach at C6/C7 region according to anatomy", "target": "Prevertebral fascial plane adjacent to longus colli while avoiding carotid, internal jugular, thyroid, esophagus, vertebral artery, and neuraxis", "needle": "22G or 25G echogenic needle sized to depth", "injectate_product": "Local anesthetic per sympathetic block protocol", "dose_volume": "Physician-selected low-volume incremental injection", "diluent_anesthetic": "Local anesthetic as selected", "total_volume": "Actual volume injected incrementally", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "next_procedure_medication_choice": "Local anesthetic per sympathetic block protocol", "next_procedure_dose": "Physician-selected low-volume incremental injection; Actual volume injected incrementally", "next_procedure_technique": "Ultrasound-guided, in-plane or out-of-plane according to anatomy and safety; Lateral-to-medial or medial-to-lateral approach at C6/C7 region according to anatomy; Prevertebral fascial plane adjacent to longus colli while avoiding carotid, internal jugular, thyroid, esophagus, vertebral artery, and neuraxis; 22G or 25G echogenic needle sized to depth", "next_procedure_patient_position": "Supine with slight neck extension and head rotated away as tolerated", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Stellate ganglion block - ultrasound-guided\n\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{guidance}} with a {{transducer}}, carotid artery, internal jugular vein, thyroid, longus colli, and surrounding structures were identified. A {{needle}} was advanced via {{approach}} to {{target}}. Needle visualization/path: {{needle_visualization}} Aspiration: {{aspiration_result}} Injection/spread: {{injection_character}}\n\nProduct/injectate: {{injectate_product}} {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Cervical spine / head", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Sympathetic block", "procedure_group": "Sympathetic blocks", "condition": "Complex regional pain syndrome; Peripheral neuropathic pain / post-herpetic neuralgia; Sympathetically maintained pain"}}, {"form_id": "ketamine_infusion_chronic_pain", "title": "Ketamine infusion for chronic pain", "region": "Infusion", "family": "Infusion therapy", "conditions": ["CRPS", "Neuropathic pain", "Fibromyalgia", "Treatment-resistant chronic pain"], "template_sheet": "Ketamine_Infusion", "status": "Expanded v0.4 procedure-specific form", "procedure_defaults": {"patient_position": "Reclined infusion chair or stretcher with IV access secured", "monitoring": "Continuous monitoring with serial vital signs, level of sedation/dissociation assessment, and rescue equipment immediately available per clinic protocol.", "guidance": "N/A - IV infusion", "guidance_phrase": "N/A - IV infusion documentation", "infusion_protocol": "Clinic ketamine infusion protocol selected by physician", "iv_access": "Peripheral IV placed and patency confirmed", "ketamine_product": "Ketamine product selected and verified against DPD/clinic inventory", "starting_rate": "Physician-prescribed starting dose/rate", "titration_plan": "Titrate according to protocol, analgesic response, side effects, and vital signs", "rescue_meds_available": "Rescue medications and airway/monitoring equipment available per clinic protocol"}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "No allergies; no active infection; anticoagulant status reviewed", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from default_monitoring_infusion."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging guidance."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolves from ultrasound_guidance_phrase."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Safety", "key": "baseline_vitals", "label": "Baseline vitals and mental status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual baseline.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "pregnancy_screen_if_applicable", "label": "Pregnancy screen if applicable", "default_layer": "No Default", "input_type": "text", "required": false, "options": "", "help": "Manual-only where relevant.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "IV", "key": "iv_access", "label": "IV access", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default; edit actual."}, {"section": "Protocol", "key": "infusion_protocol", "label": "Infusion protocol", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Procedure-specific default; physician-verifiable."}, {"section": "Medication", "key": "ketamine_product", "label": "Ketamine product/concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, concentration, lot, expiry."}, {"section": "Medication", "key": "lot_expiry", "label": "Lot number and expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["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."]}, {"section": "Dosing", "key": "starting_rate", "label": "Starting dose/rate", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure default; actual dose must be verified."}, {"section": "Dosing", "key": "titration_plan", "label": "Titration plan", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Procedure default; edit per encounter."}, {"section": "Dosing", "key": "actual_total_dose", "label": "Actual total ketamine dose administered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual dose."}, {"section": "Monitoring", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global infusion monitoring default."}, {"section": "Monitoring", "key": "intra_infusion_vitals", "label": "Intra-infusion vitals / events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual observations."}, {"section": "Safety", "key": "rescue_meds_available", "label": "Rescue medications / equipment availability", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Procedure default.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Outcome", "key": "side_effects", "label": "Side effects / dissociation / nausea / emergence symptoms", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual adverse effects.", "quick_options": ["No immediate complication observed.", "Response will be reassessed after the expected onset window."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate analgesic response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Nausea;Hypertension;Dysphoria;Over-sedation;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "discharge_criteria", "label": "Discharge criteria met", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual discharge status.", "quick_options": ["Aftercare, red flags, and follow-up plan reviewed with patient."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-infusion instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global instructions; edit for ketamine.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Ketamine Infusion for Chronic Pain\n\nIndication: Ketamine infusion for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}} Baseline: {{baseline_vitals}} Pregnancy screen if applicable: {{pregnancy_screen_if_applicable}}\n\nIV/protocol: Position: {{patient_position}}. IV access: {{iv_access}}. Protocol: {{infusion_protocol}}. Monitoring: {{monitoring}}\n\nMedication/dosing: Product/concentration: {{ketamine_product}}. Lot/expiry: {{lot_expiry}}. Starting rate: {{starting_rate}}. Titration: {{titration_plan}}. Actual total dose: {{actual_total_dose}}.\n\nCourse: Intra-infusion vitals/events: {{intra_infusion_vitals}}. Rescue meds/equipment: {{rescue_meds_available}}. Side effects: {{side_effects}}\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}. Discharge: {{discharge_criteria}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "form_type": "Procedure", "category": "Infusion therapy", "condition_tags": "CRPS; Neuropathic pain; Fibromyalgia; Treatment-resistant chronic pain", "sheet_name": "Ketamine_Infusion", "defaults": {"patient_position": "Reclined infusion chair or stretcher with IV access secured", "monitoring": "Continuous monitoring with serial vital signs, level of sedation/dissociation assessment, and rescue equipment immediately available per clinic protocol.", "guidance": "N/A - IV infusion", "guidance_phrase": "N/A - IV infusion documentation", "infusion_protocol": "Clinic ketamine infusion protocol selected by physician", "iv_access": "Peripheral IV placed and patency confirmed", "ketamine_product": "Ketamine product selected and verified against DPD/clinic inventory", "starting_rate": "Physician-prescribed starting dose/rate", "titration_plan": "Titrate according to protocol, analgesic response, side effects, and vital signs", "rescue_meds_available": "Rescue medications and airway/monitoring equipment available per clinic protocol", "next_procedure_medication_choice": "Ketamine product selected and verified against DPD/clinic inventory", "next_procedure_dose": "Same dose/volume/settings as current procedure unless changed.", "next_procedure_technique": "N/A - IV infusion", "next_procedure_patient_position": "Reclined infusion chair or stretcher with IV access secured", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "template": "Ketamine Infusion for Chronic Pain\n\nIndication: Ketamine infusion for {{diagnosis}}. {{clinical_indication}}\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}} Baseline: {{baseline_vitals}} Pregnancy screen if applicable: {{pregnancy_screen_if_applicable}}\n\nIV/protocol: Position: {{patient_position}}. IV access: {{iv_access}}. Protocol: {{infusion_protocol}}. Monitoring: {{monitoring}}\n\nMedication/dosing: Product/concentration: {{ketamine_product}}. Lot/expiry: {{lot_expiry}}. Starting rate: {{starting_rate}}. Titration: {{titration_plan}}. Actual total dose: {{actual_total_dose}}.\n\nCourse: Intra-infusion vitals/events: {{intra_infusion_vitals}}. Rescue meds/equipment: {{rescue_meds_available}}. Side effects: {{side_effects}}\n\nOutcome: Immediate response: {{immediate_response}} Complications: {{complications}}. Discharge: {{discharge_criteria}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "General / multisite pain", "condition": "Complex regional pain syndrome; Peripheral neuropathic pain / post-herpetic neuralgia; Fibromyalgia / central sensitization; Chronic post-surgical pain; Trigeminal neuralgia / facial neuropathic pain; Failed back surgery syndrome / persistent spinal pain syndrome; Phantom limb pain / stump pain; Sympathetically maintained pain; Chronic pelvic / visceral pelvic pain", "guidance_options": ["N/A"], "intervention_type": "Infusion", "procedure_group": "Epidural steroid injections (ESI)"}}, {"form_id": "dequervain_sheath_steroid_us", "title": "First dorsal compartment / De Quervain corticosteroid injection - ultrasound-guided", "region": "Wrist/hand", "family": "Tendon sheath steroid injection", "conditions": ["De Quervain tenosynovitis", "Radial wrist pain"], "condition_tags": "De Quervain tenosynovitis; Radial wrist pain", "template_sheet": "DeQuervain_US", "sheet_name": "DeQuervain_US", "form_type": "Procedure", "category": "Tendon sheath steroid injection", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Seated or supine with wrist supported, thumb side accessible", "guidance": "Ultrasound-guided, in-plane or out-of-plane as anatomy dictates", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer_or_equipment": "High-frequency linear transducer", "approach": "Needle directed into first dorsal extensor compartment sheath, avoiding superficial radial nerve branches", "target": "Tendon sheath around APL/EPB within first dorsal compartment; subcompartment targeted if seen", "needle": "25G 1.0-1.5 inch needle", "injectate_product": "Small-dose corticosteroid with local anesthetic; verify product/DIN", "dose_volume": "Low-volume injectate individualized to sheath capacity", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 0.5-2 mL; verify actual", "next_procedure_medication_choice": "Small-dose corticosteroid with local anesthetic; verify product/DIN", "next_procedure_dose": "Low-volume injectate individualized to sheath capacity; Typical total 0.5-2 mL; verify actual", "next_procedure_technique": "Ultrasound-guided, in-plane or out-of-plane as anatomy dictates; Needle directed into first dorsal extensor compartment sheath, avoiding superficial radial nerve branches; Tendon sheath around APL/EPB within first dorsal compartment; subcompartment targeted if seen; 25G 1.0-1.5 inch needle", "next_procedure_patient_position": "Seated or supine with wrist supported, thumb side accessible", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: First dorsal compartment / De Quervain corticosteroid injection - ultrasound-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Wrist / hand", "condition": "De Quervain tenosynovitis", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Tendon / enthesis procedures"}}, {"form_id": "trigger_finger_steroid_us", "title": "Flexor tendon sheath corticosteroid injection for trigger finger - ultrasound-guided", "region": "Hand", "family": "Tendon sheath steroid injection", "conditions": ["Trigger finger", "Stenosing tenosynovitis"], "condition_tags": "Trigger finger; Stenosing tenosynovitis", "template_sheet": "TriggerFinger_US", "sheet_name": "TriggerFinger_US", "form_type": "Procedure", "category": "Tendon sheath steroid injection", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Seated or supine with hand supinated and digit supported", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer_or_equipment": "High-frequency linear transducer", "approach": "In-plane approach toward flexor tendon sheath at A1 pulley region", "target": "Flexor tendon sheath at A1 pulley, avoiding intratendinous injection", "needle": "25G 1.0-1.5 inch needle", "injectate_product": "Small-dose corticosteroid with local anesthetic; verify product/DIN", "dose_volume": "Low-volume injectate individualized", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 0.5-1.5 mL; verify actual", "next_procedure_medication_choice": "Small-dose corticosteroid with local anesthetic; verify product/DIN", "next_procedure_dose": "Low-volume injectate individualized; Typical total 0.5-1.5 mL; verify actual", "next_procedure_technique": "Ultrasound-guided; In-plane approach toward flexor tendon sheath at A1 pulley region; Flexor tendon sheath at A1 pulley, avoiding intratendinous injection; 25G 1.0-1.5 inch needle", "next_procedure_patient_position": "Seated or supine with hand supinated and digit supported", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Flexor tendon sheath corticosteroid injection for trigger finger - ultrasound-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Wrist / hand", "condition": "Trigger finger / stenosing tenosynovitis", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Tendon / enthesis procedures"}}, {"form_id": "thumb_cmc_steroid_us", "title": "Thumb first carpometacarpal joint corticosteroid injection - ultrasound-guided", "region": "Hand", "family": "Small joint steroid injection", "conditions": ["Thumb CMC osteoarthritis", "Basal thumb arthritis"], "condition_tags": "Thumb CMC osteoarthritis; Basal thumb arthritis", "template_sheet": "ThumbCMC_US", "sheet_name": "ThumbCMC_US", "form_type": "Procedure", "category": "Small joint steroid injection", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Seated or supine with thumb/wrist supported", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer_or_equipment": "High-frequency linear transducer", "approach": "In-plane approach to first CMC joint recess, avoiding radial artery/superficial radial nerve", "target": "First carpometacarpal joint space", "needle": "25G 1.0-1.5 inch needle", "injectate_product": "Small-dose corticosteroid with local anesthetic; verify product/DIN", "dose_volume": "Low-volume joint injection individualized", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 0.5-1.5 mL; verify actual", "next_procedure_medication_choice": "Small-dose corticosteroid with local anesthetic; verify product/DIN", "next_procedure_dose": "Low-volume joint injection individualized; Typical total 0.5-1.5 mL; verify actual", "next_procedure_technique": "Ultrasound-guided; In-plane approach to first CMC joint recess, avoiding radial artery/superficial radial nerve; First carpometacarpal joint space; 25G 1.0-1.5 inch needle", "next_procedure_patient_position": "Seated or supine with thumb/wrist supported", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Thumb first carpometacarpal joint corticosteroid injection - ultrasound-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Wrist / hand", "condition": "Thumb CMC osteoarthritis", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Joint injections"}}, {"form_id": "wrist_joint_steroid_us", "title": "Radiocarpal wrist joint corticosteroid injection - ultrasound-guided", "region": "Wrist", "family": "Small joint steroid injection", "conditions": ["Wrist osteoarthritis", "Inflammatory wrist arthropathy", "Chronic wrist pain"], "condition_tags": "Wrist osteoarthritis; Inflammatory wrist arthropathy; Chronic wrist pain", "template_sheet": "WristJoint_US", "sheet_name": "WristJoint_US", "form_type": "Procedure", "category": "Small joint steroid injection", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Seated with forearm pronated and wrist supported", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer_or_equipment": "High-frequency linear transducer", "approach": "Dorsal in-plane approach to radiocarpal recess", "target": "Radiocarpal joint recess", "needle": "25G 1.0-1.5 inch needle", "injectate_product": "Corticosteroid with local anesthetic; verify product/DIN", "dose_volume": "Low-volume joint injection individualized", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 1-2 mL; verify actual", "next_procedure_medication_choice": "Corticosteroid with local anesthetic; verify product/DIN", "next_procedure_dose": "Low-volume joint injection individualized; Typical total 1-2 mL; verify actual", "next_procedure_technique": "Ultrasound-guided; Dorsal in-plane approach to radiocarpal recess; Radiocarpal joint recess; 25G 1.0-1.5 inch needle", "next_procedure_patient_position": "Seated with forearm pronated and wrist supported", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Radiocarpal wrist joint corticosteroid injection - ultrasound-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Wrist / hand", "condition": "Wrist osteoarthritis; Inflammatory wrist arthropathy; Chronic wrist pain", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Joint injections"}}, {"form_id": "elbow_joint_steroid_us", "title": "Elbow joint corticosteroid injection - ultrasound-guided", "region": "Elbow", "family": "Joint steroid injection", "conditions": ["Elbow osteoarthritis", "Inflammatory elbow arthropathy", "Chronic elbow pain"], "condition_tags": "Elbow osteoarthritis; Inflammatory elbow arthropathy; Chronic elbow pain", "template_sheet": "ElbowJoint_US", "sheet_name": "ElbowJoint_US", "form_type": "Procedure", "category": "Joint steroid injection", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Seated or supine with elbow supported", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer_or_equipment": "High-frequency linear transducer", "approach": "Posterolateral or posterior approach depending on effusion/recess and anatomy", "target": "Elbow joint recess", "needle": "22-25G 1.5 inch needle", "injectate_product": "Corticosteroid with local anesthetic; verify product/DIN", "dose_volume": "Physician-selected steroid dose with local anesthetic", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 2-4 mL; verify actual", "next_procedure_medication_choice": "Corticosteroid with local anesthetic; verify product/DIN", "next_procedure_dose": "Physician-selected steroid dose with local anesthetic; Typical total 2-4 mL; verify actual", "next_procedure_technique": "Ultrasound-guided; Posterolateral or posterior approach depending on effusion/recess and anatomy; Elbow joint recess; 22-25G 1.5 inch needle", "next_procedure_patient_position": "Seated or supine with elbow supported", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Elbow joint corticosteroid injection - ultrasound-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Elbow", "condition": "Elbow osteoarthritis; Inflammatory elbow arthropathy; Chronic elbow pain", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Joint injections"}}, {"form_id": "medial_epicondyle_prp_us", "title": "Medial epicondyle PRP injection / tendon fenestration - ultrasound-guided", "region": "Elbow", "family": "PRP / tendon fenestration", "conditions": ["Medial epicondylalgia", "Common flexor tendinopathy"], "condition_tags": "Medial epicondylalgia; Common flexor tendinopathy", "template_sheet": "MedEpic_PRP_US", "sheet_name": "MedEpic_PRP_US", "form_type": "Procedure", "category": "PRP / tendon fenestration", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Seated or supine with elbow supported and medial elbow accessible", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer_or_equipment": "High-frequency linear transducer", "approach": "In-plane approach to common flexor tendon origin, avoiding ulnar nerve", "target": "Common flexor tendon origin / hypoechoic tendinopathic region", "needle": "22-25G needle selected for tendon fenestration and PRP injection", "injectate_product": "Autologous PRP preparation; verify preparation system/device status and protocol", "dose_volume": "PRP volume individualized to tendon size and target", "diluent_anesthetic": "Local anesthetic limited/avoided in target tendon region according to PRP protocol", "total_volume": "Typical total 1-4 mL PRP; verify actual", "next_procedure_medication_choice": "Autologous PRP preparation; verify preparation system/device status and protocol", "next_procedure_dose": "PRP volume individualized to tendon size and target; Typical total 1-4 mL PRP; verify actual", "next_procedure_technique": "Ultrasound-guided; In-plane approach to common flexor tendon origin, avoiding ulnar nerve; Common flexor tendon origin / hypoechoic tendinopathic region; 22-25G needle selected for tendon fenestration and PRP injection", "next_procedure_patient_position": "Seated or supine with elbow supported and medial elbow accessible", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Medial epicondyle PRP injection / tendon fenestration - ultrasound-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Elbow", "condition": "Medial epicondylalgia", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regenerative / viscosupplementation", "procedure_group": "Tendon / enthesis procedures"}}, {"form_id": "patellar_tendon_prp_us", "title": "Patellar tendon PRP injection / fenestration - ultrasound-guided", "region": "Knee", "family": "PRP / tendon fenestration", "conditions": ["Patellar tendinopathy", "Jumper knee"], "condition_tags": "Patellar tendinopathy; Jumper knee", "template_sheet": "Patellar_PRP_US", "sheet_name": "Patellar_PRP_US", "form_type": "Procedure", "category": "PRP / tendon fenestration", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Supine with knee supported and patellar tendon accessible", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer_or_equipment": "High-frequency linear transducer", "approach": "In-plane approach to tendinopathic patellar tendon region", "target": "Hypoechoic/pathologic patellar tendon region, avoiding intratendinous bolus if protocol requires peritendinous placement", "needle": "22-25G needle selected for fenestration/PRP", "injectate_product": "Autologous PRP preparation; verify preparation system/device status and protocol", "dose_volume": "PRP volume individualized", "diluent_anesthetic": "Local anesthetic limited/avoided at tendon target according to PRP protocol", "total_volume": "Typical total 1-4 mL PRP; verify actual", "next_procedure_medication_choice": "Autologous PRP preparation; verify preparation system/device status and protocol", "next_procedure_dose": "PRP volume individualized; Typical total 1-4 mL PRP; verify actual", "next_procedure_technique": "Ultrasound-guided; In-plane approach to tendinopathic patellar tendon region; Hypoechoic/pathologic patellar tendon region, avoiding intratendinous bolus if protocol requires peritendinous placement; 22-25G needle selected for fenestration/PRP", "next_procedure_patient_position": "Supine with knee supported and patellar tendon accessible", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Patellar tendon PRP injection / fenestration - ultrasound-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Knee", "condition": "Knee osteoarthritis / chronic knee pain; Patellar tendinopathy", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regenerative / viscosupplementation", "procedure_group": "Tendon / enthesis procedures"}}, {"form_id": "achilles_tendon_prp_us", "title": "Achilles tendon PRP injection / fenestration - ultrasound-guided", "region": "Ankle/foot", "family": "PRP / tendon fenestration", "conditions": ["Achilles tendinopathy", "Insertional Achilles pain"], "condition_tags": "Achilles tendinopathy; Insertional Achilles pain", "template_sheet": "Achilles_PRP_US", "sheet_name": "Achilles_PRP_US", "form_type": "Procedure", "category": "PRP / tendon fenestration", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Prone with feet over edge or supine/side-lying depending on target", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer_or_equipment": "High-frequency linear transducer", "approach": "In-plane approach to tendinopathic Achilles region, avoiding neurovascular structures", "target": "Tendinopathic Achilles tendon/peritendinous target based on protocol", "needle": "22-25G needle selected for fenestration/PRP", "injectate_product": "Autologous PRP preparation; verify preparation system/device status and protocol", "dose_volume": "PRP volume individualized", "diluent_anesthetic": "Local anesthetic limited/avoided at tendon target according to PRP protocol", "total_volume": "Typical total 1-4 mL PRP; verify actual", "next_procedure_medication_choice": "Autologous PRP preparation; verify preparation system/device status and protocol", "next_procedure_dose": "PRP volume individualized; Typical total 1-4 mL PRP; verify actual", "next_procedure_technique": "Ultrasound-guided; In-plane approach to tendinopathic Achilles region, avoiding neurovascular structures; Tendinopathic Achilles tendon/peritendinous target based on protocol; 22-25G needle selected for fenestration/PRP", "next_procedure_patient_position": "Prone with feet over edge or supine/side-lying depending on target", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Achilles tendon PRP injection / fenestration - ultrasound-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Foot / ankle", "condition": "Achilles tendinopathy", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regenerative / viscosupplementation", "procedure_group": "Tendon / enthesis procedures"}}, {"form_id": "ankle_joint_steroid_us", "title": "Tibiotalar ankle joint corticosteroid injection - ultrasound-guided", "region": "Ankle/foot", "family": "Joint steroid injection", "conditions": ["Ankle osteoarthritis", "Inflammatory ankle arthropathy", "Chronic ankle pain"], "condition_tags": "Ankle osteoarthritis; Inflammatory ankle arthropathy; Chronic ankle pain", "template_sheet": "AnkleJoint_US", "sheet_name": "AnkleJoint_US", "form_type": "Procedure", "category": "Joint steroid injection", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Supine with ankle supported and slight plantarflexion as needed", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer_or_equipment": "High-frequency linear transducer", "approach": "Anterior approach between tendons/neurovascular structures according to sonographic anatomy", "target": "Tibiotalar joint recess", "needle": "22-25G 1.5 inch needle", "injectate_product": "Corticosteroid with local anesthetic; verify product/DIN", "dose_volume": "Physician-selected steroid dose with local anesthetic", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 1-3 mL; verify actual", "next_procedure_medication_choice": "Corticosteroid with local anesthetic; verify product/DIN", "next_procedure_dose": "Physician-selected steroid dose with local anesthetic; Typical total 1-3 mL; verify actual", "next_procedure_technique": "Ultrasound-guided; Anterior approach between tendons/neurovascular structures according to sonographic anatomy; Tibiotalar joint recess; 22-25G 1.5 inch needle", "next_procedure_patient_position": "Supine with ankle supported and slight plantarflexion as needed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Tibiotalar ankle joint corticosteroid injection - ultrasound-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Foot / ankle", "condition": "Ankle osteoarthritis", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Joint injections"}}, {"form_id": "mortons_neuroma_injection_us", "title": "Morton neuroma / intermetatarsal space injection - ultrasound-guided", "region": "Ankle/foot", "family": "Peripheral nerve / soft tissue injection", "conditions": ["Morton neuroma", "Intermetatarsal neuralgia", "Forefoot pain"], "condition_tags": "Morton neuroma; Intermetatarsal neuralgia; Forefoot pain", "template_sheet": "Morton_US", "sheet_name": "Morton_US", "form_type": "Procedure", "category": "Peripheral nerve / soft tissue injection", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Supine or seated with forefoot supported", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer_or_equipment": "High-frequency linear transducer", "approach": "Dorsal or plantar approach to intermetatarsal space depending on anatomy and preference", "target": "Intermetatarsal neuroma/perineural space", "needle": "25G 1.0-1.5 inch needle", "injectate_product": "Corticosteroid/local anesthetic or alternative selected product; verify product/DIN", "dose_volume": "Low-volume perineural/intermetatarsal injectate individualized", "diluent_anesthetic": "Lidocaine 1% or preservative-free local anesthetic as selected", "total_volume": "Typical total 0.5-2 mL; verify actual", "next_procedure_medication_choice": "Corticosteroid/local anesthetic or alternative selected product; verify product/DIN", "next_procedure_dose": "Low-volume perineural/intermetatarsal injectate individualized; Typical total 0.5-2 mL; verify actual", "next_procedure_technique": "Ultrasound-guided; Dorsal or plantar approach to intermetatarsal space depending on anatomy and preference; Intermetatarsal neuroma/perineural space; 25G 1.0-1.5 inch needle", "next_procedure_patient_position": "Supine or seated with forefoot supported", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Morton neuroma / intermetatarsal space injection - ultrasound-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Foot / ankle", "condition": "Morton neuroma / forefoot neuralgia", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Peripheral nerve blocks"}}, {"form_id": "cervical_esi_fluoro", "title": "Cervical interlaminar epidural steroid injection - fluoroscopy-guided", "region": "Spine", "family": "Epidural steroid injection", "conditions": ["Cervical radicular pain", "Cervical disc/stenosis-related pain"], "condition_tags": "Cervical radicular pain; Cervical disc/stenosis-related pain", "template_sheet": "Cervical_ESI", "sheet_name": "Cervical_ESI", "form_type": "Procedure", "category": "Epidural steroid injection", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Prone with cervical spine positioned for fluoroscopic access", "monitoring": "Clinically appropriate monitoring was used. The patient was observed after the procedure per clinic protocol.", "guidance": "Fluoroscopy-guided", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "transducer_or_equipment": "Fluoroscopy unit; contrast if clinically appropriate and not contraindicated", "approach": "Interlaminar approach at physician-selected level", "target": "Cervical epidural space", "needle": "Tuohy epidural needle selected by proceduralist", "injectate_product": "Steroid/local anesthetic/saline combination selected by physician; verify product/DIN", "dose_volume": "Physician-selected dose and volume according to level and risk", "diluent_anesthetic": "Preservative-free local anesthetic/saline if used", "total_volume": "Actual volume must be documented", "next_procedure_medication_choice": "Steroid/local anesthetic/saline combination selected by physician; verify product/DIN", "next_procedure_dose": "Physician-selected dose and volume according to level and risk; Actual volume must be documented", "next_procedure_technique": "Fluoroscopy-guided; Interlaminar approach at physician-selected level; Cervical epidural space; Tuohy epidural needle selected by proceduralist", "next_procedure_patient_position": "Prone with cervical spine positioned for fluoroscopic access", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Fluoroscopy", "key": "contrast_used", "label": "Contrast use and pattern", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual contrast pattern and safety."}, {"section": "Fluoroscopy", "key": "radiation_details", "label": "Fluoroscopy time / dose if tracked", "default_layer": "No Default", "input_type": "text", "required": false, "options": "", "help": "Manual-only if available."}, {"section": "Fluoroscopy", "key": "neuro_status", "label": "Pre/post neurologic status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only neurologic status."}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Cervical interlaminar epidural steroid injection - fluoroscopy-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Cervical spine / head", "condition": "Cervical radicular pain", "guidance_options": ["Fluoroscopy-guided"], "intervention_type": "Injection", "procedure_group": "Epidural steroid injections (ESI)"}}, {"form_id": "thoracic_mbb", "title": "Thoracic medial branch diagnostic block - image-guided", "region": "Spine", "family": "Diagnostic medial branch block", "conditions": ["Thoracic facet-mediated pain", "Thoracic axial pain"], "condition_tags": "Thoracic facet-mediated pain; Thoracic axial pain", "template_sheet": "Thoracic_MBB", "sheet_name": "Thoracic_MBB", "form_type": "Procedure", "category": "Diagnostic medial branch block", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Prone with thoracic spine exposed", "guidance": "Fluoroscopy or ultrasound-guided according to anatomy and clinic protocol", "guidance_phrase": "Image guidance was used with relevant bony landmarks and safety structures identified.", "transducer_or_equipment": "Fluoroscopy or ultrasound equipment as used", "approach": "Needle placement to thoracic medial branch target at selected levels", "target": "Thoracic medial branch target points at documented levels", "needle": "22-25G spinal needle selected by proceduralist", "injectate_product": "Local anesthetic diagnostic injectate; verify product/DIN", "dose_volume": "Low-volume diagnostic local anesthetic per target", "diluent_anesthetic": "Local anesthetic selected for diagnostic block", "total_volume": "Actual volume per target and total documented", "next_procedure_medication_choice": "Local anesthetic diagnostic injectate; verify product/DIN", "next_procedure_dose": "Low-volume diagnostic local anesthetic per target; Actual volume per target and total documented", "next_procedure_technique": "Fluoroscopy or ultrasound-guided according to anatomy and clinic protocol; Needle placement to thoracic medial branch target at selected levels; Thoracic medial branch target points at documented levels; 22-25G spinal needle selected by proceduralist", "next_procedure_patient_position": "Prone with thoracic spine exposed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Thoracic medial branch diagnostic block - image-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Thoracic spine / chest wall", "condition": "Thoracic facet / rib / chest wall pain", "guidance_options": ["Ultrasound-guided", "Fluoroscopy-guided"], "intervention_type": "Block / hydrodissection", "procedure_group": "Facet / medial branch procedures"}}, {"form_id": "thoracic_medial_branch_rfa", "title": "Thoracic medial branch radiofrequency ablation", "region": "Spine", "family": "Radiofrequency ablation", "conditions": ["Thoracic facet-mediated pain", "Thoracic axial pain"], "condition_tags": "Thoracic facet-mediated pain; Thoracic axial pain", "template_sheet": "Thoracic_RFA", "sheet_name": "Thoracic_RFA", "form_type": "Procedure", "category": "Radiofrequency ablation", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Prone with thoracic spine exposed", "monitoring": "Non-invasive monitoring was used as clinically indicated. The patient remained communicative during stimulation and lesioning unless otherwise documented.", "guidance": "Image-guided per clinic protocol", "guidance_phrase": "Image guidance was used to localize thoracic medial branch target points and adjacent structures.", "transducer_or_equipment": "RF generator and image guidance system", "approach": "RF cannula placement to selected thoracic medial branch targets", "target": "Thoracic medial branch nerves at documented levels", "needle": "RF cannula selected by proceduralist", "injectate_product": "Local anesthetic before lesioning; post-lesion injectate if used", "dose_volume": "Local anesthetic volume per target; verify actual", "diluent_anesthetic": "Preservative-free local anesthetic as selected", "total_volume": "Actual volume documented", "rf_generator": "Clinic RF generator; verify device/licence/service status", "rf_cannula": "RF cannula with active tip selected by physician", "lesion_settings": "Thermal RF settings per physician protocol; actual settings documented", "next_procedure_medication_choice": "Local anesthetic before lesioning; post-lesion injectate if used", "next_procedure_dose": "Local anesthetic volume per target; verify actual; Actual volume documented; Thermal RF settings per physician protocol; actual settings documented", "next_procedure_technique": "Image-guided per clinic protocol; RF cannula placement to selected thoracic medial branch targets; Thoracic medial branch nerves at documented levels; RF cannula selected by proceduralist", "next_procedure_patient_position": "Prone with thoracic spine exposed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating nerve ablation/RFA, usual interval is about every year or longer unless physician documents a different rationale; reassess indication, diagnostic response, neurologic status, and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "RFA", "key": "rf_generator", "label": "RF generator / system", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify device/licence and clinic inventory."}, {"section": "RFA", "key": "rf_cannula", "label": "RF cannula / active tip", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit actual."}, {"section": "RFA", "key": "sensory_stimulation", "label": "Sensory stimulation result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual stimulation result."}, {"section": "RFA", "key": "motor_stimulation", "label": "Motor stimulation result", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual motor stimulation/safety."}, {"section": "RFA", "key": "lesion_settings", "label": "Lesion settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; actual settings must be checked."}, {"section": "RFA", "key": "lesion_count", "label": "Number of lesions / sites", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual count."}, {"section": "RFA", "key": "post_lesion_injectate", "label": "Post-lesion injectate if used", "default_layer": "No Default", "input_type": "text", "required": false, "options": "", "help": "Manual-only if used."}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Thoracic medial branch radiofrequency ablation\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Thoracic spine / chest wall", "condition": "Thoracic facet / rib / chest wall pain", "guidance_options": ["Image-guided / other"], "intervention_type": "Ablation / PRF", "procedure_group": "Facet / medial branch procedures"}}, {"form_id": "coccyx_ganglion_impar_block_fluoro", "title": "Ganglion impar / coccygeal sympathetic block - fluoroscopy-guided", "region": "Pelvis/coccyx", "family": "Sympathetic / pelvic pain block", "conditions": ["Coccydynia", "Pelvic/perineal sympathetic pain"], "condition_tags": "Coccydynia; Pelvic/perineal sympathetic pain", "template_sheet": "GanglionImpar", "sheet_name": "GanglionImpar", "form_type": "Procedure", "category": "Sympathetic / pelvic pain block", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Prone with pelvis/coccyx positioned for fluoroscopic access", "guidance": "Fluoroscopy-guided", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions.", "transducer_or_equipment": "Fluoroscopy unit; contrast if clinically appropriate and not contraindicated", "approach": "Trans-sacrococcygeal or intercoccygeal approach according to anatomy", "target": "Ganglion impar region anterior to sacrococcygeal junction/coccyx", "needle": "Spinal needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid or other physician-selected injectate; verify product/DIN", "dose_volume": "Physician-selected volume and medication", "diluent_anesthetic": "Preservative-free local anesthetic as selected", "total_volume": "Actual volume documented", "next_procedure_medication_choice": "Local anesthetic with/without steroid or other physician-selected injectate; verify product/DIN", "next_procedure_dose": "Physician-selected volume and medication; Actual volume documented", "next_procedure_technique": "Fluoroscopy-guided; Trans-sacrococcygeal or intercoccygeal approach according to anatomy; Ganglion impar region anterior to sacrococcygeal junction/coccyx; Spinal needle selected by proceduralist", "next_procedure_patient_position": "Prone with pelvis/coccyx positioned for fluoroscopic access", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Fluoroscopy", "key": "contrast_used", "label": "Contrast use and pattern", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual contrast pattern and safety."}, {"section": "Fluoroscopy", "key": "radiation_details", "label": "Fluoroscopy time / dose if tracked", "default_layer": "No Default", "input_type": "text", "required": false, "options": "", "help": "Manual-only if available."}, {"section": "Fluoroscopy", "key": "neuro_status", "label": "Pre/post neurologic status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only neurologic status."}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Ganglion impar / coccygeal sympathetic block - fluoroscopy-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Coccydynia; Pudendal neuralgia / pelvic pain; Chronic pelvic / visceral pelvic pain", "guidance_options": ["Fluoroscopy-guided"], "intervention_type": "Block / hydrodissection", "procedure_group": "Office-based pain procedure"}}, {"form_id": "pudendal_nerve_block_us", "title": "Pudendal nerve block - ultrasound-guided", "region": "Pelvis", "family": "Peripheral nerve block", "conditions": ["Pudendal neuralgia", "Chronic pelvic/perineal pain"], "condition_tags": "Pudendal neuralgia; Chronic pelvic/perineal pain", "template_sheet": "Pudendal_US", "sheet_name": "Pudendal_US", "form_type": "Procedure", "category": "Peripheral nerve block", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Prone, lateral, or lithotomy-compatible position according to approach and patient tolerance", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer_or_equipment": "Curvilinear or linear transducer as anatomy requires", "approach": "Approach to pudendal nerve region near ischial spine/Alcock canal depending on selected technique", "target": "Perineural pudendal nerve region, avoiding vascular structures", "needle": "Spinal or block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid; verify product/DIN", "dose_volume": "Physician-selected perineural injectate volume", "diluent_anesthetic": "Preservative-free local anesthetic as selected", "total_volume": "Actual volume documented", "next_procedure_medication_choice": "Local anesthetic with/without steroid; verify product/DIN", "next_procedure_dose": "Physician-selected perineural injectate volume; Actual volume documented", "next_procedure_technique": "Ultrasound-guided; Approach to pudendal nerve region near ischial spine/Alcock canal depending on selected technique; Perineural pudendal nerve region, avoiding vascular structures; Spinal or block needle selected by proceduralist", "next_procedure_patient_position": "Prone, lateral, or lithotomy-compatible position according to approach and patient tolerance", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Pudendal nerve block - ultrasound-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Pudendal neuralgia / pelvic pain; Chronic pelvic / visceral pelvic pain", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Block / hydrodissection", "procedure_group": "Peripheral nerve blocks"}}, {"form_id": "superior_cluneal_nerve_block_us", "title": "Superior cluneal nerve block - ultrasound-guided", "region": "Pelvis/low back", "family": "Peripheral nerve block", "conditions": ["Superior cluneal neuralgia", "Iliac crest pain", "Chronic low back pain"], "condition_tags": "Superior cluneal neuralgia; Iliac crest pain; Chronic low back pain", "template_sheet": "Cluneal_US", "sheet_name": "Cluneal_US", "form_type": "Procedure", "category": "Peripheral nerve block", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Prone with iliac crest accessible", "guidance": "Ultrasound-guided or landmark-assisted according to anatomy", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer_or_equipment": "High-frequency linear transducer", "approach": "Needle directed to superior cluneal nerve fascial plane over iliac crest", "target": "Superior cluneal nerve region/fascial plane near posterior iliac crest", "needle": "22-25G needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid; verify product/DIN", "dose_volume": "Low-to-moderate volume fascial/perineural injectate", "diluent_anesthetic": "Local anesthetic selected by physician", "total_volume": "Actual volume documented", "next_procedure_medication_choice": "Local anesthetic with/without steroid; verify product/DIN", "next_procedure_dose": "Low-to-moderate volume fascial/perineural injectate; Actual volume documented", "next_procedure_technique": "Ultrasound-guided or landmark-assisted according to anatomy; Needle directed to superior cluneal nerve fascial plane over iliac crest; Superior cluneal nerve region/fascial plane near posterior iliac crest; 22-25G needle selected by proceduralist", "next_procedure_patient_position": "Prone with iliac crest accessible", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Superior cluneal nerve block - ultrasound-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Superior cluneal neuralgia", "guidance_options": ["Ultrasound-guided", "Landmark-guided"], "intervention_type": "Block / hydrodissection", "procedure_group": "Peripheral nerve blocks"}}, {"form_id": "quadratus_lumborum_block_us", "title": "Quadratus lumborum fascial plane block - ultrasound-guided", "region": "Trunk/abdominal wall", "family": "Regional anesthesia / fascial plane blocks", "conditions": ["Chronic flank pain", "Abdominal wall pain", "Trunk pain"], "condition_tags": "Flank pain; Low back / pelvic regional pain; Post-surgical abdominal wall pain", "template_sheet": "QL_Block_US", "sheet_name": "QL_Block_US", "form_type": "Procedure", "category": "Regional anesthesia / fascial plane blocks", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Lateral or supine/oblique position depending on selected QL approach", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer_or_equipment": "Curvilinear or linear transducer as anatomy requires", "approach": "Lateral/posterior/anterior QL approach as selected and documented", "target": "Fascial plane adjacent to quadratus lumborum muscle", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without adjunct; verify product/DIN", "dose_volume": "Volume/concentration selected within safety limits", "diluent_anesthetic": "Preservative-free local anesthetic as selected", "total_volume": "Actual volume documented", "next_procedure_medication_choice": "Local anesthetic with/without adjunct; verify product/DIN", "next_procedure_dose": "Volume/concentration selected within safety limits; Actual volume documented", "next_procedure_technique": "Ultrasound-guided; Lateral/posterior/anterior QL approach as selected and documented; Fascial plane adjacent to quadratus lumborum muscle; Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Lateral or supine/oblique position depending on selected QL approach", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Quadratus lumborum fascial plane block - ultrasound-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "procedure_defaults": {"patient_position": "Lateral, prone, or supine according to approach", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Lateral, posterior, or transmuscular QL approach as selected", "target": "Quadratus lumborum fascial plane target selected by approach", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without adjunct as selected; verify dose", "dose_volume": "Plane block volume/concentration selected within safety limits", "diluent_anesthetic": "Medication mix selected by physician and documented."}, "navigator": {"region": "Lumbar spine", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regional block", "procedure_group": "Regional anesthesia / fascial plane blocks", "condition": "Sacroiliac joint pain / posterior pelvic pain; Lumbar facet-mediated pain; Chronic post-surgical pain; Flank pain / thoracolumbar regional pain"}}, {"form_id": "erector_spinae_plane_block_us", "title": "Erector spinae plane block - ultrasound-guided", "region": "Thoracic/lumbar trunk", "family": "Regional anesthesia / fascial plane blocks", "conditions": ["Thoracic wall pain", "Rib pain", "Chronic trunk pain"], "condition_tags": "Thoracic pain; Rib/chest wall pain; Lumbar myofascial or regional pain", "template_sheet": "ESP_Block_US", "sheet_name": "ESP_Block_US", "form_type": "Procedure", "category": "Regional anesthesia / fascial plane blocks", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Sitting, lateral, or prone according to target level and tolerance", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer_or_equipment": "Linear or curvilinear transducer depending on depth", "approach": "In-plane approach to deep aspect of erector spinae muscle at selected transverse process level", "target": "Erector spinae fascial plane at documented vertebral level", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without adjunct; verify product/DIN", "dose_volume": "Volume/concentration selected within safety limits", "diluent_anesthetic": "Preservative-free local anesthetic as selected", "total_volume": "Actual volume documented", "next_procedure_medication_choice": "Local anesthetic with/without adjunct; verify product/DIN", "next_procedure_dose": "Volume/concentration selected within safety limits; Actual volume documented", "next_procedure_technique": "Ultrasound-guided; In-plane approach to deep aspect of erector spinae muscle at selected transverse process level; Erector spinae fascial plane at documented vertebral level; Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Sitting, lateral, or prone according to target level and tolerance", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Erector spinae plane block - ultrasound-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "procedure_defaults": {"patient_position": "Prone, lateral, or seated according to target level", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane approach to transverse process / fascial plane endpoint", "target": "Erector spinae fascial plane at selected vertebral level(s)", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid or adjunct as selected; verify dose", "dose_volume": "Plane block volume/concentration selected within safety limits", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected."}, "navigator": {"region": "Thoracic spine / ribs", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regional block", "procedure_group": "Regional anesthesia / fascial plane blocks", "condition": "Lumbar facet-mediated pain; Thoracic facet / rib / chest wall pain; Intercostal neuralgia / post-thoracotomy pain; Chronic post-surgical pain; Flank pain / thoracolumbar regional pain"}}, {"form_id": "shoulder_capsular_hydrodilatation_us", "title": "Shoulder capsular hydrodilatation - ultrasound-guided", "region": "Shoulder", "family": "Capsular distension injection", "conditions": ["Adhesive capsulitis", "Frozen shoulder"], "condition_tags": "Adhesive capsulitis; Frozen shoulder", "template_sheet": "ShoulderHydro_US", "sheet_name": "ShoulderHydro_US", "form_type": "Procedure", "category": "Capsular distension injection", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Lateral decubitus or seated with shoulder positioned for posterior glenohumeral access", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer_or_equipment": "High-frequency linear or curvilinear transducer", "approach": "Posterior in-plane glenohumeral joint approach", "target": "Posterior glenohumeral joint recess/capsule", "needle": "22G spinal or 1.5-3.5 inch needle based on depth", "injectate_product": "Local anesthetic/saline with or without corticosteroid; verify product/DIN", "dose_volume": "Capsular distension volume selected by physician and patient tolerance", "diluent_anesthetic": "Saline and local anesthetic as selected", "total_volume": "Actual distension volume documented", "next_procedure_medication_choice": "Local anesthetic/saline with or without corticosteroid; verify product/DIN", "next_procedure_dose": "Capsular distension volume selected by physician and patient tolerance; Actual distension volume documented", "next_procedure_technique": "Ultrasound-guided; Posterior in-plane glenohumeral joint approach; Posterior glenohumeral joint recess/capsule; 22G spinal or 1.5-3.5 inch needle based on depth", "next_procedure_patient_position": "Lateral decubitus or seated with shoulder positioned for posterior glenohumeral access", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Shoulder capsular hydrodilatation - ultrasound-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Shoulder", "condition": "Shoulder osteoarthritis / adhesive capsulitis", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Epidural steroid injections (ESI)"}}, {"form_id": "ankle_joint_ha_us", "title": "Tibiotalar ankle joint hyaluronic acid injection - ultrasound-guided", "region": "Ankle/foot", "family": "Hyaluronic acid joint injection", "conditions": ["Ankle osteoarthritis", "Chronic ankle pain"], "condition_tags": "Ankle osteoarthritis; Chronic ankle pain", "template_sheet": "Ankle_HA_US", "sheet_name": "Ankle_HA_US", "form_type": "Procedure", "category": "Hyaluronic acid joint injection", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Supine with ankle supported and slight plantarflexion as needed", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location and relevant surrounding structures were visualized throughout needle advancement as feasible.", "transducer_or_equipment": "High-frequency linear transducer", "approach": "Anterior approach to tibiotalar joint recess avoiding tendons/neurovascular structures", "target": "Tibiotalar joint space", "needle": "22-25G needle compatible with selected HA product", "injectate_product": "Hyaluronic acid product selected by patient/physician; verify product/licence/inventory", "dose_volume": "Product-specific prefilled syringe volume; verify actual", "diluent_anesthetic": "Local anesthetic if used; avoid mixing unless product protocol permits", "total_volume": "Product-specific; document actual", "next_procedure_medication_choice": "Hyaluronic acid product selected by patient/physician; verify product/licence/inventory", "next_procedure_dose": "Product-specific prefilled syringe volume; verify actual; Product-specific; document actual", "next_procedure_technique": "Ultrasound-guided; Anterior approach to tibiotalar joint recess avoiding tendons/neurovascular structures; Tibiotalar joint space; 22-25G needle compatible with selected HA product", "next_procedure_patient_position": "Supine with ankle supported and slight plantarflexion as needed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Tibiotalar ankle joint hyaluronic acid injection - ultrasound-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Foot / ankle", "condition": "Ankle osteoarthritis", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regenerative / viscosupplementation", "procedure_group": "Joint injections"}}, {"form_id": "facet_intraarticular_lumbar_steroid", "title": "Lumbar facet intra-articular corticosteroid injection - image-guided", "region": "Spine", "family": "Facet joint steroid injection", "conditions": ["Lumbar facet arthropathy", "Axial low back pain"], "condition_tags": "Lumbar facet arthropathy; Axial low back pain", "template_sheet": "LumbarFacet_IA", "sheet_name": "LumbarFacet_IA", "form_type": "Procedure", "category": "Facet joint steroid injection", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Prone with lumbar spine exposed", "guidance": "Fluoroscopy or ultrasound-guided according to anatomy and clinic protocol", "guidance_phrase": "Image guidance was used to identify the facet joint target and adjacent safety structures.", "transducer_or_equipment": "Image guidance equipment as used", "approach": "Posterior/oblique approach to selected lumbar facet joint", "target": "Lumbar facet joint space at documented level(s)", "needle": "Spinal needle selected by proceduralist", "injectate_product": "Corticosteroid/local anesthetic mixture; verify product/DIN", "dose_volume": "Low-volume joint injectate per level", "diluent_anesthetic": "Local anesthetic as selected", "total_volume": "Actual volume per joint and total documented", "next_procedure_medication_choice": "Corticosteroid/local anesthetic mixture; verify product/DIN", "next_procedure_dose": "Low-volume joint injectate per level; Actual volume per joint and total documented", "next_procedure_technique": "Fluoroscopy or ultrasound-guided according to anatomy and clinic protocol; Posterior/oblique approach to selected lumbar facet joint; Lumbar facet joint space at documented level(s); Spinal needle selected by proceduralist", "next_procedure_patient_position": "Prone with lumbar spine exposed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Lumbar facet intra-articular corticosteroid injection - image-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Lumbar spine", "condition": "Lumbar facet-mediated pain", "guidance_options": ["Ultrasound-guided", "Fluoroscopy-guided"], "intervention_type": "Injection", "procedure_group": "Facet / medial branch procedures"}}, {"form_id": "facet_intraarticular_cervical_steroid", "title": "Cervical facet intra-articular corticosteroid injection - image-guided", "region": "Spine", "family": "Facet joint steroid injection", "conditions": ["Cervical facet arthropathy", "Axial neck pain"], "condition_tags": "Cervical facet arthropathy; Axial neck pain", "template_sheet": "CervFacet_IA", "sheet_name": "CervFacet_IA", "form_type": "Procedure", "category": "Facet joint steroid injection", "status": "Added v0.5 expanded procedure form", "defaults": {"patient_position": "Prone or lateral/oblique positioning according to image-guided technique", "guidance": "Fluoroscopy or ultrasound-guided according to anatomy and clinic protocol", "guidance_phrase": "Image guidance was used to identify the cervical facet target and adjacent safety structures.", "transducer_or_equipment": "Image guidance equipment as used", "approach": "Image-guided approach to selected cervical facet joint", "target": "Cervical facet joint space at documented level(s)", "needle": "Spinal needle selected by proceduralist", "injectate_product": "Corticosteroid/local anesthetic mixture; verify product/DIN", "dose_volume": "Low-volume joint injectate per level", "diluent_anesthetic": "Local anesthetic as selected", "total_volume": "Actual volume per joint and total documented", "next_procedure_medication_choice": "Corticosteroid/local anesthetic mixture; verify product/DIN", "next_procedure_dose": "Low-volume joint injectate per level; Actual volume per joint and total documented", "next_procedure_technique": "Fluoroscopy or ultrasound-guided according to anatomy and clinic protocol; Image-guided approach to selected cervical facet joint; Cervical facet joint space at documented level(s); Spinal needle selected by proceduralist", "next_procedure_patient_position": "Prone or lateral/oblique positioning according to image-guided technique", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks and alternatives.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Confirm patient, procedure, side/site/level, allergies, anticoagulants, infection screen, and planned injectate/settings.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication / rationale", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for today procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Side / level / site", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain score and functional limitation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline for response tracking.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Resolve from monitoring default; edit if sedation/infusion/RFA."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to form."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Use ultrasound/fluoroscopy phrase as applicable."}, {"section": "Guidance", "key": "image_saved", "label": "Image saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only image documentation.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Procedure-specific device/equipment detail."}, {"section": "Technique", "key": "approach", "label": "Approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique approach for this form."}, {"section": "Technique", "key": "target", "label": "Target / endpoint", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for this form."}, {"section": "Technique", "key": "needle", "label": "Needle/cannula", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form needle/cannula default; edit if changed."}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / localization", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / safety check result", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection spread / resistance / observation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread, resistance, paresthesia, or pain reproduction.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Injectate/product/device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form product default; verify product/licence before use."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / amount / concentration", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form expected dose/volume; actual must be verified."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Local anesthetic / diluent", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Per-form default if applicable."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form default; verify actual total.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot number / expiry", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only. Do not default.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / post-procedure status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response and status.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse events", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual complications or none.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "template": "Procedure: Cervical facet intra-articular corticosteroid injection - image-guided\nIndication: {{diagnosis}}. Clinical rationale: {{clinical_indication}}. Side/site/level: {{side}}. Baseline pain/function: {{baseline_pain_function}}.\n\nConsent and safety: {{consent_phrase}} {{timeout_phrase}} {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}}. {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Image documentation: {{image_saved}}.\n\nTechnique: Using {{transducer_or_equipment}}, {{approach}}. A {{needle}} was advanced toward {{target}}. Localization/visualization: {{needle_visualization}}. Aspiration/safety check: {{aspiration_result}}. Injection/lesion/procedural observation: {{injection_character}}.\n\nInjectate/product/device: {{injectate_product}}. Dose/amount: {{dose_volume}}. Local anesthetic/diluent: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.\n\nOutcome: Immediate response/status: {{immediate_response}}. Complications/adverse events: {{complications}}.\n\nDisposition: {{post_procedure_instructions}} Follow-up: {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Cervical spine / head", "condition": "Cervical facet-mediated pain", "guidance_options": ["Ultrasound-guided", "Fluoroscopy-guided"], "intervention_type": "Injection", "procedure_group": "Facet / medial branch procedures"}}, {"form_id": "hist_knee_osteoarthritis", "title": "History - Knee osteoarthritis / chronic knee pain", "region": "Condition history", "family": "History", "conditions": ["Knee osteoarthritis / chronic knee pain"], "condition_tags": "Knee osteoarthritis / chronic knee pain", "template_sheet": "Hx Knee osteoarthritis chronic", "sheet_name": "Hx Knee osteoarthritis chronic", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Knee osteoarthritis / chronic knee pain", "condition_specific_questions": "Mechanical symptoms, effusion, stair tolerance, gait aid use, prior arthroplasty status.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Knee osteoarthritis / chronic knee pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["knee_ia_steroid_us", "knee_ia_ha_us", "knee_ia_prp_us", "knee_periarticular_prolo_us", "genicular_rfa", "patellar_tendon_prp_us"], "navigator": {"region": "Knee", "condition": "Knee osteoarthritis / chronic knee pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_knee_osteoarthritis", "title": "Physical exam - Knee osteoarthritis / chronic knee pain", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Knee osteoarthritis / chronic knee pain"], "condition_tags": "Knee osteoarthritis / chronic knee pain", "template_sheet": "PE Knee osteoarthritis chronic", "sheet_name": "PE Knee osteoarthritis chronic", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Knee osteoarthritis / chronic knee pain", "condition_specific_exam": "Mechanical symptoms, effusion, stair tolerance, gait aid use, prior arthroplasty status.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Knee osteoarthritis / chronic knee pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["knee_ia_steroid_us", "knee_ia_ha_us", "knee_ia_prp_us", "knee_periarticular_prolo_us", "genicular_rfa", "patellar_tendon_prp_us"], "navigator": {"region": "Knee", "condition": "Knee osteoarthritis / chronic knee pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_hip_osteoarthritis", "title": "History - Hip osteoarthritis / chronic groin pain", "region": "Condition history", "family": "History", "conditions": ["Hip osteoarthritis / chronic groin pain"], "condition_tags": "Hip osteoarthritis / chronic groin pain", "template_sheet": "Hx Hip osteoarthritis chronic", "sheet_name": "Hx Hip osteoarthritis chronic", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Hip osteoarthritis / chronic groin pain", "condition_specific_questions": "Groin vs lateral pain, mechanical limitation, walking distance, prior imaging.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Hip osteoarthritis / chronic groin pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["hip_ia_steroid_us", "hip_ia_prp_us"], "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Hip osteoarthritis / chronic groin pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_hip_osteoarthritis", "title": "Physical exam - Hip osteoarthritis / chronic groin pain", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Hip osteoarthritis / chronic groin pain"], "condition_tags": "Hip osteoarthritis / chronic groin pain", "template_sheet": "PE Hip osteoarthritis chronic", "sheet_name": "PE Hip osteoarthritis chronic", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Hip osteoarthritis / chronic groin pain", "condition_specific_exam": "Groin vs lateral pain, mechanical limitation, walking distance, prior imaging.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Hip osteoarthritis / chronic groin pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["hip_ia_steroid_us", "hip_ia_prp_us"], "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Hip osteoarthritis / chronic groin pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_shoulder_oa_capsulitis", "title": "History - Shoulder osteoarthritis / adhesive capsulitis", "region": "Condition history", "family": "History", "conditions": ["Shoulder osteoarthritis / adhesive capsulitis"], "condition_tags": "Shoulder osteoarthritis / adhesive capsulitis", "template_sheet": "Hx Shoulder osteoarthritis adhe", "sheet_name": "Hx Shoulder osteoarthritis adhe", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Shoulder osteoarthritis / adhesive capsulitis", "condition_specific_questions": "Passive range limitation, capsular pattern, night pain, diabetes/thyroid association.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Shoulder osteoarthritis / adhesive capsulitis\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["shoulder_gh_steroid_us", "shoulder_gh_prp_us", "shoulder_capsular_hydrodilatation_us", "suprascapular_nerve_block_us"], "navigator": {"region": "Shoulder", "condition": "Shoulder osteoarthritis / adhesive capsulitis", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_shoulder_oa_capsulitis", "title": "Physical exam - Shoulder osteoarthritis / adhesive capsulitis", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Shoulder osteoarthritis / adhesive capsulitis"], "condition_tags": "Shoulder osteoarthritis / adhesive capsulitis", "template_sheet": "PE Shoulder osteoarthritis adhe", "sheet_name": "PE Shoulder osteoarthritis adhe", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Shoulder osteoarthritis / adhesive capsulitis", "condition_specific_exam": "Passive range limitation, capsular pattern, night pain, diabetes/thyroid association.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Shoulder osteoarthritis / adhesive capsulitis\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["shoulder_gh_steroid_us", "shoulder_gh_prp_us", "shoulder_capsular_hydrodilatation_us", "suprascapular_nerve_block_us"], "navigator": {"region": "Shoulder", "condition": "Shoulder osteoarthritis / adhesive capsulitis", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_rotator_cuff_subacromial", "title": "History - Rotator cuff tendinopathy / subacromial pain", "region": "Condition history", "family": "History", "conditions": ["Rotator cuff tendinopathy / subacromial pain"], "condition_tags": "Rotator cuff tendinopathy / subacromial pain", "template_sheet": "Hx Rotator cuff tendinopathy", "sheet_name": "Hx Rotator cuff tendinopathy", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Rotator cuff tendinopathy / subacromial pain", "condition_specific_questions": "Painful arc, weakness pattern, night pain, overhead activity limitation.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Rotator cuff tendinopathy / subacromial pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["shoulder_subacromial_steroid_us", "shoulder_tendon_prp_us", "suprascapular_nerve_block_us"], "navigator": {"region": "Shoulder", "condition": "Rotator cuff tendinopathy / subacromial pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_rotator_cuff_subacromial", "title": "Physical exam - Rotator cuff tendinopathy / subacromial pain", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Rotator cuff tendinopathy / subacromial pain"], "condition_tags": "Rotator cuff tendinopathy / subacromial pain", "template_sheet": "PE Rotator cuff tendinopathy", "sheet_name": "PE Rotator cuff tendinopathy", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Rotator cuff tendinopathy / subacromial pain", "condition_specific_exam": "Painful arc, weakness pattern, night pain, overhead activity limitation.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Rotator cuff tendinopathy / subacromial pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["shoulder_subacromial_steroid_us", "shoulder_tendon_prp_us", "suprascapular_nerve_block_us"], "navigator": {"region": "Shoulder", "condition": "Rotator cuff tendinopathy / subacromial pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_ac_joint_arthropathy", "title": "History - Acromioclavicular joint arthropathy", "region": "Condition history", "family": "History", "conditions": ["Acromioclavicular joint arthropathy"], "condition_tags": "Acromioclavicular joint arthropathy", "template_sheet": "Hx Acromioclavicular joint arth", "sheet_name": "Hx Acromioclavicular joint arth", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Acromioclavicular joint arthropathy", "condition_specific_questions": "Cross-body adduction pain, superior shoulder pain, trauma history.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Acromioclavicular joint arthropathy\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["ac_joint_steroid_us"], "navigator": {"region": "Shoulder", "condition": "Acromioclavicular joint arthropathy", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_ac_joint_arthropathy", "title": "Physical exam - Acromioclavicular joint arthropathy", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Acromioclavicular joint arthropathy"], "condition_tags": "Acromioclavicular joint arthropathy", "template_sheet": "PE Acromioclavicular joint arth", "sheet_name": "PE Acromioclavicular joint arth", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Acromioclavicular joint arthropathy", "condition_specific_exam": "Cross-body adduction pain, superior shoulder pain, trauma history.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Acromioclavicular joint arthropathy\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["ac_joint_steroid_us"], "navigator": {"region": "Shoulder", "condition": "Acromioclavicular joint arthropathy", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_biceps_tendinopathy", "title": "History - Long head biceps tendinopathy", "region": "Condition history", "family": "History", "conditions": ["Long head biceps tendinopathy"], "condition_tags": "Long head biceps tendinopathy", "template_sheet": "Hx Long head biceps", "sheet_name": "Hx Long head biceps", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Long head biceps tendinopathy", "condition_specific_questions": "Anterior shoulder pain, lifting/supination provocation, pulley instability symptoms.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Long head biceps tendinopathy\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["shoulder_tendon_prp_us"], "navigator": {"region": "Shoulder", "condition": "Long head biceps tendinopathy", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_biceps_tendinopathy", "title": "Physical exam - Long head biceps tendinopathy", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Long head biceps tendinopathy"], "condition_tags": "Long head biceps tendinopathy", "template_sheet": "PE Long head biceps", "sheet_name": "PE Long head biceps", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Long head biceps tendinopathy", "condition_specific_exam": "Anterior shoulder pain, lifting/supination provocation, pulley instability symptoms.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Long head biceps tendinopathy\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["shoulder_tendon_prp_us"], "navigator": {"region": "Shoulder", "condition": "Long head biceps tendinopathy", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_gtps", "title": "History - Greater trochanteric pain syndrome", "region": "Condition history", "family": "History", "conditions": ["Greater trochanteric pain syndrome"], "condition_tags": "Greater trochanteric pain syndrome", "template_sheet": "Hx Greater trochanteric pain", "sheet_name": "Hx Greater trochanteric pain", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Greater trochanteric pain syndrome", "condition_specific_questions": "Lateral hip pain, side-lying intolerance, gluteal weakness, lumbar overlap.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Greater trochanteric pain syndrome\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["gt_bursa_gluteal_tendon_steroid_us", "hip_prp_us"], "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Greater trochanteric pain syndrome", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_gtps", "title": "Physical exam - Greater trochanteric pain syndrome", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Greater trochanteric pain syndrome"], "condition_tags": "Greater trochanteric pain syndrome", "template_sheet": "PE Greater trochanteric pain", "sheet_name": "PE Greater trochanteric pain", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Greater trochanteric pain syndrome", "condition_specific_exam": "Lateral hip pain, side-lying intolerance, gluteal weakness, lumbar overlap.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Greater trochanteric pain syndrome\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["gt_bursa_gluteal_tendon_steroid_us", "hip_prp_us"], "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Greater trochanteric pain syndrome", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_piriformis_deep_gluteal", "title": "History - Piriformis / deep gluteal pain", "region": "Condition history", "family": "History", "conditions": ["Piriformis / deep gluteal pain"], "condition_tags": "Piriformis / deep gluteal pain", "template_sheet": "Hx Piriformis deep gluteal", "sheet_name": "Hx Piriformis deep gluteal", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Piriformis / deep gluteal pain", "condition_specific_questions": "Buttock pain, sitting intolerance, sciatic-like symptoms, hip rotation provocation.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Piriformis / deep gluteal pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["piriformis_injection_us"], "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Piriformis / deep gluteal pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_piriformis_deep_gluteal", "title": "Physical exam - Piriformis / deep gluteal pain", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Piriformis / deep gluteal pain"], "condition_tags": "Piriformis / deep gluteal pain", "template_sheet": "PE Piriformis deep gluteal", "sheet_name": "PE Piriformis deep gluteal", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Piriformis / deep gluteal pain", "condition_specific_exam": "Buttock pain, sitting intolerance, sciatic-like symptoms, hip rotation provocation.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Piriformis / deep gluteal pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["piriformis_injection_us"], "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Piriformis / deep gluteal pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_sacroiliac_joint_pain", "title": "History - Sacroiliac joint pain / posterior pelvic pain", "region": "Condition history", "family": "History", "conditions": ["Sacroiliac joint pain / posterior pelvic pain"], "condition_tags": "Sacroiliac joint pain / posterior pelvic pain", "template_sheet": "Hx Sacroiliac joint pain", "sheet_name": "Hx Sacroiliac joint pain", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Sacroiliac joint pain / posterior pelvic pain", "condition_specific_questions": "PSIS-region pain, Fortin area, provocation tests, pregnancy/trauma history.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Sacroiliac joint pain / posterior pelvic pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["si_joint_steroid_us", "si_ligament_prolo_us"], "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Sacroiliac joint pain / posterior pelvic pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_sacroiliac_joint_pain", "title": "Physical exam - Sacroiliac joint pain / posterior pelvic pain", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Sacroiliac joint pain / posterior pelvic pain"], "condition_tags": "Sacroiliac joint pain / posterior pelvic pain", "template_sheet": "PE Sacroiliac joint pain", "sheet_name": "PE Sacroiliac joint pain", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Sacroiliac joint pain / posterior pelvic pain", "condition_specific_exam": "PSIS-region pain, Fortin area, provocation tests, pregnancy/trauma history.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Sacroiliac joint pain / posterior pelvic pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["si_joint_steroid_us", "si_ligament_prolo_us"], "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Sacroiliac joint pain / posterior pelvic pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_lumbar_facet_pain", "title": "History - Lumbar facet-mediated pain", "region": "Condition history", "family": "History", "conditions": ["Lumbar facet-mediated pain"], "condition_tags": "Lumbar facet-mediated pain", "template_sheet": "Hx Lumbar facetmediated pain", "sheet_name": "Hx Lumbar facetmediated pain", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Lumbar facet-mediated pain", "condition_specific_questions": "Extension/rotation pain, axial predominance, diagnostic block history.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Lumbar facet-mediated pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["lumbar_mbb", "lumbar_medial_branch_rfa", "facet_intraarticular_lumbar_steroid"], "navigator": {"region": "Lumbar spine", "condition": "Lumbar facet-mediated pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_lumbar_facet_pain", "title": "Physical exam - Lumbar facet-mediated pain", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Lumbar facet-mediated pain"], "condition_tags": "Lumbar facet-mediated pain", "template_sheet": "PE Lumbar facetmediated pain", "sheet_name": "PE Lumbar facetmediated pain", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Lumbar facet-mediated pain", "condition_specific_exam": "Extension/rotation pain, axial predominance, diagnostic block history.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Lumbar facet-mediated pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["lumbar_mbb", "lumbar_medial_branch_rfa", "facet_intraarticular_lumbar_steroid"], "navigator": {"region": "Lumbar spine", "condition": "Lumbar facet-mediated pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_cervical_facet_pain", "title": "History - Cervical facet-mediated pain", "region": "Condition history", "family": "History", "conditions": ["Cervical facet-mediated pain"], "condition_tags": "Cervical facet-mediated pain", "template_sheet": "Hx Cervical facetmediated pain", "sheet_name": "Hx Cervical facetmediated pain", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Cervical facet-mediated pain", "condition_specific_questions": "Axial neck pain, headache referral, rotation/extension triggers.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Cervical facet-mediated pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["cervical_mbb", "cervical_medial_branch_rfa", "facet_intraarticular_cervical_steroid"], "navigator": {"region": "Cervical spine / head", "condition": "Cervical facet-mediated pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_cervical_facet_pain", "title": "Physical exam - Cervical facet-mediated pain", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Cervical facet-mediated pain"], "condition_tags": "Cervical facet-mediated pain", "template_sheet": "PE Cervical facetmediated pain", "sheet_name": "PE Cervical facetmediated pain", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Cervical facet-mediated pain", "condition_specific_exam": "Axial neck pain, headache referral, rotation/extension triggers.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Cervical facet-mediated pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["cervical_mbb", "cervical_medial_branch_rfa", "facet_intraarticular_cervical_steroid"], "navigator": {"region": "Cervical spine / head", "condition": "Cervical facet-mediated pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_thoracic_facet_rib_pain", "title": "History - Thoracic facet / rib / chest wall pain", "region": "Condition history", "family": "History", "conditions": ["Thoracic facet / rib / chest wall pain"], "condition_tags": "Thoracic facet / rib / chest wall pain", "template_sheet": "Hx Thoracic facet rib", "sheet_name": "Hx Thoracic facet rib", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Thoracic facet / rib / chest wall pain", "condition_specific_questions": "Thoracic axial pain, rib referral, respiratory/movement provocation.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Thoracic facet / rib / chest wall pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["thoracic_mbb", "thoracic_medial_branch_rfa", "intercostal_nerve_block_us", "erector_spinae_plane_block_us"], "navigator": {"region": "Thoracic spine / chest wall", "condition": "Thoracic facet / rib / chest wall pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_thoracic_facet_rib_pain", "title": "Physical exam - Thoracic facet / rib / chest wall pain", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Thoracic facet / rib / chest wall pain"], "condition_tags": "Thoracic facet / rib / chest wall pain", "template_sheet": "PE Thoracic facet rib", "sheet_name": "PE Thoracic facet rib", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Thoracic facet / rib / chest wall pain", "condition_specific_exam": "Thoracic axial pain, rib referral, respiratory/movement provocation.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Thoracic facet / rib / chest wall pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["thoracic_mbb", "thoracic_medial_branch_rfa", "intercostal_nerve_block_us", "erector_spinae_plane_block_us"], "navigator": {"region": "Thoracic spine / chest wall", "condition": "Thoracic facet / rib / chest wall pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_lumbar_radiculopathy", "title": "History - Lumbar radicular pain / sciatica", "region": "Condition history", "family": "History", "conditions": ["Lumbar radicular pain / sciatica"], "condition_tags": "Lumbar radicular pain / sciatica", "template_sheet": "Hx Lumbar radicular pain", "sheet_name": "Hx Lumbar radicular pain", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Lumbar radicular pain / sciatica", "condition_specific_questions": "Dermatomal pain, neurologic symptoms, imaging-level correlation, red flags.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Lumbar radicular pain / sciatica\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["tf_snerb_esi_fluoro", "caudal_esi_fluoro"], "navigator": {"region": "Lumbar spine", "condition": "Lumbar radicular pain / sciatica", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_lumbar_radiculopathy", "title": "Physical exam - Lumbar radicular pain / sciatica", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Lumbar radicular pain / sciatica"], "condition_tags": "Lumbar radicular pain / sciatica", "template_sheet": "PE Lumbar radicular pain", "sheet_name": "PE Lumbar radicular pain", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Lumbar radicular pain / sciatica", "condition_specific_exam": "Dermatomal pain, neurologic symptoms, imaging-level correlation, red flags.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Lumbar radicular pain / sciatica\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["tf_snerb_esi_fluoro", "caudal_esi_fluoro"], "navigator": {"region": "Lumbar spine", "condition": "Lumbar radicular pain / sciatica", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_cervical_radiculopathy", "title": "History - Cervical radicular pain", "region": "Condition history", "family": "History", "conditions": ["Cervical radicular pain"], "condition_tags": "Cervical radicular pain", "template_sheet": "Hx Cervical radicular pain", "sheet_name": "Hx Cervical radicular pain", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Cervical radicular pain", "condition_specific_questions": "Arm pain distribution, neurologic symptoms, imaging correlation, myelopathy screen.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Cervical radicular pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["cervical_esi_fluoro"], "navigator": {"region": "Cervical spine / head", "condition": "Cervical radicular pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_cervical_radiculopathy", "title": "Physical exam - Cervical radicular pain", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Cervical radicular pain"], "condition_tags": "Cervical radicular pain", "template_sheet": "PE Cervical radicular pain", "sheet_name": "PE Cervical radicular pain", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Cervical radicular pain", "condition_specific_exam": "Arm pain distribution, neurologic symptoms, imaging correlation, myelopathy screen.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Cervical radicular pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["cervical_esi_fluoro"], "navigator": {"region": "Cervical spine / head", "condition": "Cervical radicular pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_myofascial_pain", "title": "History - Myofascial pain syndrome", "region": "Condition history", "family": "History", "conditions": ["Myofascial pain syndrome"], "condition_tags": "Myofascial pain syndrome", "template_sheet": "Hx Myofascial pain syndrome", "sheet_name": "Hx Myofascial pain syndrome", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Myofascial pain syndrome", "condition_specific_questions": "Trigger points, taut bands, postural/occupational factors, sleep and stress.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Myofascial pain syndrome\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["trigger_point_injections"], "navigator": {"region": "General / multisite pain", "condition": "Myofascial pain syndrome", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_myofascial_pain", "title": "Physical exam - Myofascial pain syndrome", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Myofascial pain syndrome"], "condition_tags": "Myofascial pain syndrome", "template_sheet": "PE Myofascial pain syndrome", "sheet_name": "PE Myofascial pain syndrome", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Myofascial pain syndrome", "condition_specific_exam": "Trigger points, taut bands, postural/occupational factors, sleep and stress.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Myofascial pain syndrome\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["trigger_point_injections"], "navigator": {"region": "General / multisite pain", "condition": "Myofascial pain syndrome", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_occipital_neuralgia", "title": "History - Occipital neuralgia / cervicogenic headache", "region": "Condition history", "family": "History", "conditions": ["Occipital neuralgia / cervicogenic headache"], "condition_tags": "Occipital neuralgia / cervicogenic headache", "template_sheet": "Hx Occipital neuralgia cervicog", "sheet_name": "Hx Occipital neuralgia cervicog", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Occipital neuralgia / cervicogenic headache", "condition_specific_questions": "Headache distribution, allodynia, neck triggers, migraine overlap.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Occipital neuralgia / cervicogenic headache\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["occipital_nerve_block_us", "cervical_mbb"], "navigator": {"region": "Cervical spine / head", "condition": "Occipital neuralgia / cervicogenic headache", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_occipital_neuralgia", "title": "Physical exam - Occipital neuralgia / cervicogenic headache", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Occipital neuralgia / cervicogenic headache"], "condition_tags": "Occipital neuralgia / cervicogenic headache", "template_sheet": "PE Occipital neuralgia cervicog", "sheet_name": "PE Occipital neuralgia cervicog", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Occipital neuralgia / cervicogenic headache", "condition_specific_exam": "Headache distribution, allodynia, neck triggers, migraine overlap.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Occipital neuralgia / cervicogenic headache\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["occipital_nerve_block_us", "cervical_mbb"], "navigator": {"region": "Cervical spine / head", "condition": "Occipital neuralgia / cervicogenic headache", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_carpal_tunnel", "title": "History - Carpal tunnel syndrome", "region": "Condition history", "family": "History", "conditions": ["Carpal tunnel syndrome"], "condition_tags": "Carpal tunnel syndrome", "template_sheet": "Hx Carpal tunnel syndrome", "sheet_name": "Hx Carpal tunnel syndrome", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Carpal tunnel syndrome", "condition_specific_questions": "Median sensory symptoms, nocturnal symptoms, thenar weakness, EMG/imaging.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Carpal tunnel syndrome\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["median_nerve_hydrodissection_us", "carpal_tunnel_steroid_us"], "navigator": {"region": "Wrist / hand", "condition": "Carpal tunnel syndrome", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_carpal_tunnel", "title": "Physical exam - Carpal tunnel syndrome", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Carpal tunnel syndrome"], "condition_tags": "Carpal tunnel syndrome", "template_sheet": "PE Carpal tunnel syndrome", "sheet_name": "PE Carpal tunnel syndrome", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Carpal tunnel syndrome", "condition_specific_exam": "Median sensory symptoms, nocturnal symptoms, thenar weakness, EMG/imaging.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Carpal tunnel syndrome\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["median_nerve_hydrodissection_us", "carpal_tunnel_steroid_us"], "navigator": {"region": "Wrist / hand", "condition": "Carpal tunnel syndrome", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_dequervain", "title": "History - De Quervain tenosynovitis", "region": "Condition history", "family": "History", "conditions": ["De Quervain tenosynovitis"], "condition_tags": "De Quervain tenosynovitis", "template_sheet": "Hx De Quervain tenosynovitis", "sheet_name": "Hx De Quervain tenosynovitis", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "De Quervain tenosynovitis", "condition_specific_questions": "Radial wrist pain, thumb use, postpartum/overuse context.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: De Quervain tenosynovitis\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["dequervain_sheath_steroid_us"], "navigator": {"region": "Wrist / hand", "condition": "De Quervain tenosynovitis", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_dequervain", "title": "Physical exam - De Quervain tenosynovitis", "region": "Condition exam", "family": "Physical Exam", "conditions": ["De Quervain tenosynovitis"], "condition_tags": "De Quervain tenosynovitis", "template_sheet": "PE De Quervain tenosynovitis", "sheet_name": "PE De Quervain tenosynovitis", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "De Quervain tenosynovitis", "condition_specific_exam": "Radial wrist pain, thumb use, postpartum/overuse context.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: De Quervain tenosynovitis\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["dequervain_sheath_steroid_us"], "navigator": {"region": "Wrist / hand", "condition": "De Quervain tenosynovitis", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_thumb_cmc_oa", "title": "History - Thumb CMC osteoarthritis", "region": "Condition history", "family": "History", "conditions": ["Thumb CMC osteoarthritis"], "condition_tags": "Thumb CMC osteoarthritis", "template_sheet": "Hx Thumb CMC osteoarthritis", "sheet_name": "Hx Thumb CMC osteoarthritis", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Thumb CMC osteoarthritis", "condition_specific_questions": "Pinch/grip pain, basal thumb deformity, brace/hand therapy response.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Thumb CMC osteoarthritis\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["thumb_cmc_steroid_us", "first_cmc_steroid_us"], "navigator": {"region": "Wrist / hand", "condition": "Thumb CMC osteoarthritis", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_thumb_cmc_oa", "title": "Physical exam - Thumb CMC osteoarthritis", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Thumb CMC osteoarthritis"], "condition_tags": "Thumb CMC osteoarthritis", "template_sheet": "PE Thumb CMC osteoarthritis", "sheet_name": "PE Thumb CMC osteoarthritis", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Thumb CMC osteoarthritis", "condition_specific_exam": "Pinch/grip pain, basal thumb deformity, brace/hand therapy response.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Thumb CMC osteoarthritis\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["thumb_cmc_steroid_us", "first_cmc_steroid_us"], "navigator": {"region": "Wrist / hand", "condition": "Thumb CMC osteoarthritis", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_trigger_finger", "title": "History - Trigger finger / stenosing tenosynovitis", "region": "Condition history", "family": "History", "conditions": ["Trigger finger / stenosing tenosynovitis"], "condition_tags": "Trigger finger / stenosing tenosynovitis", "template_sheet": "Hx Trigger finger stenosing", "sheet_name": "Hx Trigger finger stenosing", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Trigger finger / stenosing tenosynovitis", "condition_specific_questions": "Triggering/locking, digit involved, diabetes association, prior injections.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Trigger finger / stenosing tenosynovitis\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["trigger_finger_steroid_us"], "navigator": {"region": "Wrist / hand", "condition": "Trigger finger / stenosing tenosynovitis", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_trigger_finger", "title": "Physical exam - Trigger finger / stenosing tenosynovitis", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Trigger finger / stenosing tenosynovitis"], "condition_tags": "Trigger finger / stenosing tenosynovitis", "template_sheet": "PE Trigger finger stenosing", "sheet_name": "PE Trigger finger stenosing", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Trigger finger / stenosing tenosynovitis", "condition_specific_exam": "Triggering/locking, digit involved, diabetes association, prior injections.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Trigger finger / stenosing tenosynovitis\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["trigger_finger_steroid_us"], "navigator": {"region": "Wrist / hand", "condition": "Trigger finger / stenosing tenosynovitis", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_lateral_epicondylalgia", "title": "History - Lateral epicondylalgia", "region": "Condition history", "family": "History", "conditions": ["Lateral epicondylalgia"], "condition_tags": "Lateral epicondylalgia", "template_sheet": "Hx Lateral epicondylalgia", "sheet_name": "Hx Lateral epicondylalgia", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Lateral epicondylalgia", "condition_specific_questions": "Grip pain, resisted wrist extension pain, work/sport load.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Lateral epicondylalgia\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["elbow_lateral_epicondyle_prp_us", "elbow_lateral_epicondyle_prolo_us"], "navigator": {"region": "Elbow", "condition": "Lateral epicondylalgia", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_lateral_epicondylalgia", "title": "Physical exam - Lateral epicondylalgia", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Lateral epicondylalgia"], "condition_tags": "Lateral epicondylalgia", "template_sheet": "PE Lateral epicondylalgia", "sheet_name": "PE Lateral epicondylalgia", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Lateral epicondylalgia", "condition_specific_exam": "Grip pain, resisted wrist extension pain, work/sport load.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Lateral epicondylalgia\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["elbow_lateral_epicondyle_prp_us", "elbow_lateral_epicondyle_prolo_us"], "navigator": {"region": "Elbow", "condition": "Lateral epicondylalgia", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_medial_epicondylalgia", "title": "History - Medial epicondylalgia", "region": "Condition history", "family": "History", "conditions": ["Medial epicondylalgia"], "condition_tags": "Medial epicondylalgia", "template_sheet": "Hx Medial epicondylalgia", "sheet_name": "Hx Medial epicondylalgia", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Medial epicondylalgia", "condition_specific_questions": "Flexor-pronator load, ulnar nerve symptoms, throwing/golf history.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Medial epicondylalgia\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["medial_epicondyle_prp_us"], "navigator": {"region": "Elbow", "condition": "Medial epicondylalgia", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_medial_epicondylalgia", "title": "Physical exam - Medial epicondylalgia", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Medial epicondylalgia"], "condition_tags": "Medial epicondylalgia", "template_sheet": "PE Medial epicondylalgia", "sheet_name": "PE Medial epicondylalgia", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Medial epicondylalgia", "condition_specific_exam": "Flexor-pronator load, ulnar nerve symptoms, throwing/golf history.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Medial epicondylalgia\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["medial_epicondyle_prp_us"], "navigator": {"region": "Elbow", "condition": "Medial epicondylalgia", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_plantar_fasciopathy", "title": "History - Plantar fasciopathy", "region": "Condition history", "family": "History", "conditions": ["Plantar fasciopathy"], "condition_tags": "Plantar fasciopathy", "template_sheet": "Hx Plantar fasciopathy", "sheet_name": "Hx Plantar fasciopathy", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Plantar fasciopathy", "condition_specific_questions": "First-step pain, footwear, calf tightness, activity load.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Plantar fasciopathy\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["plantar_fascia_prp_us"], "navigator": {"region": "Foot / ankle", "condition": "Plantar fasciopathy", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_plantar_fasciopathy", "title": "Physical exam - Plantar fasciopathy", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Plantar fasciopathy"], "condition_tags": "Plantar fasciopathy", "template_sheet": "PE Plantar fasciopathy", "sheet_name": "PE Plantar fasciopathy", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Plantar fasciopathy", "condition_specific_exam": "First-step pain, footwear, calf tightness, activity load.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Plantar fasciopathy\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["plantar_fascia_prp_us"], "navigator": {"region": "Foot / ankle", "condition": "Plantar fasciopathy", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_achilles_tendinopathy", "title": "History - Achilles tendinopathy", "region": "Condition history", "family": "History", "conditions": ["Achilles tendinopathy"], "condition_tags": "Achilles tendinopathy", "template_sheet": "Hx Achilles tendinopathy", "sheet_name": "Hx Achilles tendinopathy", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Achilles tendinopathy", "condition_specific_questions": "Midportion vs insertional pain, tendon thickening, load history.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Achilles tendinopathy\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["achilles_tendon_prp_us"], "navigator": {"region": "Foot / ankle", "condition": "Achilles tendinopathy", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_achilles_tendinopathy", "title": "Physical exam - Achilles tendinopathy", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Achilles tendinopathy"], "condition_tags": "Achilles tendinopathy", "template_sheet": "PE Achilles tendinopathy", "sheet_name": "PE Achilles tendinopathy", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Achilles tendinopathy", "condition_specific_exam": "Midportion vs insertional pain, tendon thickening, load history.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Achilles tendinopathy\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["achilles_tendon_prp_us"], "navigator": {"region": "Foot / ankle", "condition": "Achilles tendinopathy", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_patellar_tendinopathy", "title": "History - Patellar tendinopathy", "region": "Condition history", "family": "History", "conditions": ["Patellar tendinopathy"], "condition_tags": "Patellar tendinopathy", "template_sheet": "Hx Patellar tendinopathy", "sheet_name": "Hx Patellar tendinopathy", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Patellar tendinopathy", "condition_specific_questions": "Anterior knee tendon pain, jumping/squat load, tendon imaging.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Patellar tendinopathy\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["patellar_tendon_prp_us"], "navigator": {"region": "Knee", "condition": "Patellar tendinopathy", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_patellar_tendinopathy", "title": "Physical exam - Patellar tendinopathy", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Patellar tendinopathy"], "condition_tags": "Patellar tendinopathy", "template_sheet": "PE Patellar tendinopathy", "sheet_name": "PE Patellar tendinopathy", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Patellar tendinopathy", "condition_specific_exam": "Anterior knee tendon pain, jumping/squat load, tendon imaging.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Patellar tendinopathy\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["patellar_tendon_prp_us"], "navigator": {"region": "Knee", "condition": "Patellar tendinopathy", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_ankle_osteoarthritis", "title": "History - Ankle osteoarthritis", "region": "Condition history", "family": "History", "conditions": ["Ankle osteoarthritis"], "condition_tags": "Ankle osteoarthritis", "template_sheet": "Hx Ankle osteoarthritis", "sheet_name": "Hx Ankle osteoarthritis", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Ankle osteoarthritis", "condition_specific_questions": "Post-traumatic history, instability, walking tolerance, swelling.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Ankle osteoarthritis\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["ankle_joint_steroid_us", "ankle_joint_ha_us"], "navigator": {"region": "Foot / ankle", "condition": "Ankle osteoarthritis", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_ankle_osteoarthritis", "title": "Physical exam - Ankle osteoarthritis", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Ankle osteoarthritis"], "condition_tags": "Ankle osteoarthritis", "template_sheet": "PE Ankle osteoarthritis", "sheet_name": "PE Ankle osteoarthritis", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Ankle osteoarthritis", "condition_specific_exam": "Post-traumatic history, instability, walking tolerance, swelling.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Ankle osteoarthritis\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["ankle_joint_steroid_us", "ankle_joint_ha_us"], "navigator": {"region": "Foot / ankle", "condition": "Ankle osteoarthritis", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_mortons_neuroma", "title": "History - Morton neuroma / forefoot neuralgia", "region": "Condition history", "family": "History", "conditions": ["Morton neuroma / forefoot neuralgia"], "condition_tags": "Morton neuroma / forefoot neuralgia", "template_sheet": "Hx Morton neuroma forefoot", "sheet_name": "Hx Morton neuroma forefoot", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Morton neuroma / forefoot neuralgia", "condition_specific_questions": "Interdigital burning, shoe intolerance, Mulder symptoms.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Morton neuroma / forefoot neuralgia\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["mortons_neuroma_injection_us"], "navigator": {"region": "Foot / ankle", "condition": "Morton neuroma / forefoot neuralgia", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_mortons_neuroma", "title": "Physical exam - Morton neuroma / forefoot neuralgia", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Morton neuroma / forefoot neuralgia"], "condition_tags": "Morton neuroma / forefoot neuralgia", "template_sheet": "PE Morton neuroma forefoot", "sheet_name": "PE Morton neuroma forefoot", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Morton neuroma / forefoot neuralgia", "condition_specific_exam": "Interdigital burning, shoe intolerance, Mulder symptoms.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Morton neuroma / forefoot neuralgia\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["mortons_neuroma_injection_us"], "navigator": {"region": "Foot / ankle", "condition": "Morton neuroma / forefoot neuralgia", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_coccydynia", "title": "History - Coccydynia", "region": "Condition history", "family": "History", "conditions": ["Coccydynia"], "condition_tags": "Coccydynia", "template_sheet": "Hx Coccydynia", "sheet_name": "Hx Coccydynia", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Coccydynia", "condition_specific_questions": "Sitting pain, trauma/childbirth history, bowel/pelvic symptoms.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Coccydynia\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["coccyx_ganglion_impar_block_fluoro"], "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Coccydynia", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_coccydynia", "title": "Physical exam - Coccydynia", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Coccydynia"], "condition_tags": "Coccydynia", "template_sheet": "PE Coccydynia", "sheet_name": "PE Coccydynia", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Coccydynia", "condition_specific_exam": "Sitting pain, trauma/childbirth history, bowel/pelvic symptoms.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Coccydynia\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["coccyx_ganglion_impar_block_fluoro"], "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Coccydynia", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_intercostal_neuralgia", "title": "History - Intercostal neuralgia / post-thoracotomy pain", "region": "Condition history", "family": "History", "conditions": ["Intercostal neuralgia / post-thoracotomy pain"], "condition_tags": "Intercostal neuralgia / post-thoracotomy pain", "template_sheet": "Hx Intercostal neuralgia postth", "sheet_name": "Hx Intercostal neuralgia postth", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Intercostal neuralgia / post-thoracotomy pain", "condition_specific_questions": "Dermatomal chest wall pain, surgery/trauma/zoster history.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Intercostal neuralgia / post-thoracotomy pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["intercostal_nerve_block_us", "erector_spinae_plane_block_us"], "navigator": {"region": "Thoracic spine / chest wall", "condition": "Intercostal neuralgia / post-thoracotomy pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_intercostal_neuralgia", "title": "Physical exam - Intercostal neuralgia / post-thoracotomy pain", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Intercostal neuralgia / post-thoracotomy pain"], "condition_tags": "Intercostal neuralgia / post-thoracotomy pain", "template_sheet": "PE Intercostal neuralgia postth", "sheet_name": "PE Intercostal neuralgia postth", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Intercostal neuralgia / post-thoracotomy pain", "condition_specific_exam": "Dermatomal chest wall pain, surgery/trauma/zoster history.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Intercostal neuralgia / post-thoracotomy pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["intercostal_nerve_block_us", "erector_spinae_plane_block_us"], "navigator": {"region": "Thoracic spine / chest wall", "condition": "Intercostal neuralgia / post-thoracotomy pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_ilioinguinal_neuralgia", "title": "History - Ilioinguinal/iliohypogastric/genitofemoral neuralgia", "region": "Condition history", "family": "History", "conditions": ["Ilioinguinal/iliohypogastric/genitofemoral neuralgia"], "condition_tags": "Ilioinguinal/iliohypogastric/genitofemoral neuralgia", "template_sheet": "Hx Ilioinguinaliliohypogastricg", "sheet_name": "Hx Ilioinguinaliliohypogastricg", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Ilioinguinal/iliohypogastric/genitofemoral neuralgia", "condition_specific_questions": "Groin/lower abdominal neuralgia, surgery history, sensory territory.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Ilioinguinal/iliohypogastric/genitofemoral neuralgia\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["ilioinguinal_nerve_block_us"], "navigator": {"region": "General / multisite pain", "condition": "Ilioinguinal/iliohypogastric/genitofemoral neuralgia", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_ilioinguinal_neuralgia", "title": "Physical exam - Ilioinguinal/iliohypogastric/genitofemoral neuralgia", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Ilioinguinal/iliohypogastric/genitofemoral neuralgia"], "condition_tags": "Ilioinguinal/iliohypogastric/genitofemoral neuralgia", "template_sheet": "PE Ilioinguinaliliohypogastricg", "sheet_name": "PE Ilioinguinaliliohypogastricg", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Ilioinguinal/iliohypogastric/genitofemoral neuralgia", "condition_specific_exam": "Groin/lower abdominal neuralgia, surgery history, sensory territory.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Ilioinguinal/iliohypogastric/genitofemoral neuralgia\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["ilioinguinal_nerve_block_us"], "navigator": {"region": "General / multisite pain", "condition": "Ilioinguinal/iliohypogastric/genitofemoral neuralgia", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_pudendal_neuralgia", "title": "History - Pudendal neuralgia / pelvic pain", "region": "Condition history", "family": "History", "conditions": ["Pudendal neuralgia / pelvic pain"], "condition_tags": "Pudendal neuralgia / pelvic pain", "template_sheet": "Hx Pudendal neuralgia pelvic", "sheet_name": "Hx Pudendal neuralgia pelvic", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Pudendal neuralgia / pelvic pain", "condition_specific_questions": "Perineal pain, sitting intolerance, bladder/bowel/sexual symptoms.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Pudendal neuralgia / pelvic pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["pudendal_nerve_block_us", "coccyx_ganglion_impar_block_fluoro"], "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Pudendal neuralgia / pelvic pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_pudendal_neuralgia", "title": "Physical exam - Pudendal neuralgia / pelvic pain", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Pudendal neuralgia / pelvic pain"], "condition_tags": "Pudendal neuralgia / pelvic pain", "template_sheet": "PE Pudendal neuralgia pelvic", "sheet_name": "PE Pudendal neuralgia pelvic", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Pudendal neuralgia / pelvic pain", "condition_specific_exam": "Perineal pain, sitting intolerance, bladder/bowel/sexual symptoms.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Pudendal neuralgia / pelvic pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["pudendal_nerve_block_us", "coccyx_ganglion_impar_block_fluoro"], "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Pudendal neuralgia / pelvic pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_cluneal_neuralgia", "title": "History - Superior cluneal neuralgia", "region": "Condition history", "family": "History", "conditions": ["Superior cluneal neuralgia"], "condition_tags": "Superior cluneal neuralgia", "template_sheet": "Hx Superior cluneal neuralgia", "sheet_name": "Hx Superior cluneal neuralgia", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Superior cluneal neuralgia", "condition_specific_questions": "Iliac crest trigger point, low back/buttock referral.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Superior cluneal neuralgia\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["superior_cluneal_nerve_block_us"], "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Superior cluneal neuralgia", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_cluneal_neuralgia", "title": "Physical exam - Superior cluneal neuralgia", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Superior cluneal neuralgia"], "condition_tags": "Superior cluneal neuralgia", "template_sheet": "PE Superior cluneal neuralgia", "sheet_name": "PE Superior cluneal neuralgia", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Superior cluneal neuralgia", "condition_specific_exam": "Iliac crest trigger point, low back/buttock referral.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Superior cluneal neuralgia\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["superior_cluneal_nerve_block_us"], "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Superior cluneal neuralgia", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_crps", "title": "History - Complex regional pain syndrome", "region": "Condition history", "family": "History", "conditions": ["Complex regional pain syndrome"], "condition_tags": "Complex regional pain syndrome", "template_sheet": "Hx Complex regional pain", "sheet_name": "Hx Complex regional pain", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Complex regional pain syndrome", "condition_specific_questions": "Budapest criteria features, autonomic/trophic changes, limb function.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Complex regional pain syndrome\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["stellate_ganglion_block_us", "ketamine_infusion_chronic_pain"], "navigator": {"region": "General / multisite pain", "condition": "Complex regional pain syndrome", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_crps", "title": "Physical exam - Complex regional pain syndrome", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Complex regional pain syndrome"], "condition_tags": "Complex regional pain syndrome", "template_sheet": "PE Complex regional pain", "sheet_name": "PE Complex regional pain", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Complex regional pain syndrome", "condition_specific_exam": "Budapest criteria features, autonomic/trophic changes, limb function.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Complex regional pain syndrome\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["stellate_ganglion_block_us", "ketamine_infusion_chronic_pain"], "navigator": {"region": "General / multisite pain", "condition": "Complex regional pain syndrome", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_peripheral_neuropathic_pain", "title": "History - Peripheral neuropathic pain / post-herpetic neuralgia", "region": "Condition history", "family": "History", "conditions": ["Peripheral neuropathic pain / post-herpetic neuralgia"], "condition_tags": "Peripheral neuropathic pain / post-herpetic neuralgia", "template_sheet": "Hx Peripheral neuropathic pain", "sheet_name": "Hx Peripheral neuropathic pain", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Peripheral neuropathic pain / post-herpetic neuralgia", "condition_specific_questions": "Allodynia, sensory changes, zoster/diabetes/trauma context.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Peripheral neuropathic pain / post-herpetic neuralgia\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["trigger_point_injections", "intercostal_nerve_block_us", "ketamine_infusion_chronic_pain"], "navigator": {"region": "General / multisite pain", "condition": "Peripheral neuropathic pain / post-herpetic neuralgia", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_peripheral_neuropathic_pain", "title": "Physical exam - Peripheral neuropathic pain / post-herpetic neuralgia", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Peripheral neuropathic pain / post-herpetic neuralgia"], "condition_tags": "Peripheral neuropathic pain / post-herpetic neuralgia", "template_sheet": "PE Peripheral neuropathic pain", "sheet_name": "PE Peripheral neuropathic pain", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Peripheral neuropathic pain / post-herpetic neuralgia", "condition_specific_exam": "Allodynia, sensory changes, zoster/diabetes/trauma context.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Peripheral neuropathic pain / post-herpetic neuralgia\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["trigger_point_injections", "intercostal_nerve_block_us", "ketamine_infusion_chronic_pain"], "navigator": {"region": "General / multisite pain", "condition": "Peripheral neuropathic pain / post-herpetic neuralgia", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_fibromyalgia_central_sensitization", "title": "History - Fibromyalgia / central sensitization", "region": "Condition history", "family": "History", "conditions": ["Fibromyalgia / central sensitization"], "condition_tags": "Fibromyalgia / central sensitization", "template_sheet": "Hx Fibromyalgia central sensiti", "sheet_name": "Hx Fibromyalgia central sensiti", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Fibromyalgia / central sensitization", "condition_specific_questions": "Widespread pain, fatigue, sleep, mood, cognitive symptoms.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Fibromyalgia / central sensitization\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["ketamine_infusion_chronic_pain", "trigger_point_injections"], "navigator": {"region": "Central sensitization / infusion", "condition": "Fibromyalgia / central sensitization", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_fibromyalgia_central_sensitization", "title": "Physical exam - Fibromyalgia / central sensitization", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Fibromyalgia / central sensitization"], "condition_tags": "Fibromyalgia / central sensitization", "template_sheet": "PE Fibromyalgia central sensiti", "sheet_name": "PE Fibromyalgia central sensiti", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Fibromyalgia / central sensitization", "condition_specific_exam": "Widespread pain, fatigue, sleep, mood, cognitive symptoms.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Fibromyalgia / central sensitization\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["ketamine_infusion_chronic_pain", "trigger_point_injections"], "navigator": {"region": "Central sensitization / infusion", "condition": "Fibromyalgia / central sensitization", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_chronic_post_surgical_pain", "title": "History - Chronic post-surgical pain", "region": "Condition history", "family": "History", "conditions": ["Chronic post-surgical pain"], "condition_tags": "Chronic post-surgical pain", "template_sheet": "Hx Chronic postsurgical pain", "sheet_name": "Hx Chronic postsurgical pain", "form_type": "History", "category": "History", "status": "Added v0.5 condition-specific history form", "defaults": {"condition_focus": "Chronic post-surgical pain", "condition_specific_questions": "Surgery type, scar/allodynia, neuropathic features, functional impact.", "history_followup_phrase": "Plan reviewed with patient, including conservative measures, interventional options when appropriate, and follow-up based on clinical response."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / reason for visit", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location and distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "onset_duration_course", "label": "Onset, duration, and course", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "mechanism_context", "label": "Mechanism/context and relevant history", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "History", "key": "pain_quality_pattern", "label": "Pain quality, pattern, severity", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "History", "key": "aggravating_relieving", "label": "Aggravating and relieving factors", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Function", "key": "functional_limitations", "label": "Functional limitations and goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Condition-specific", "key": "condition_specific_questions", "label": "Condition-specific history prompts", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual answers."}, {"section": "Treatment history", "key": "prior_treatments", "label": "Prior conservative/interventional treatments and response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Treatment history", "key": "current_medications", "label": "Current pain medications / relevant medication issues", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Diagnostics", "key": "imaging_labs_tests", "label": "Imaging/labs/EMG and relevant reports reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Safety", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic / systemic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Context", "key": "psychosocial_sleep_mood", "label": "Sleep, mood, psychosocial and work/compensation context", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "patient_preferences_affordability", "label": "Patient preferences, affordability constraints, and treatment priorities", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_impression_plan", "label": "History-based impression and plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Plan", "key": "history_followup_phrase", "label": "History follow-up phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit according to plan."}], "template": "History template: Chronic post-surgical pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nPresenting problem: {{presenting_complaint}}. Pain location/distribution: {{pain_location_distribution}}. Onset/course: {{onset_duration_course}}. Mechanism/context: {{mechanism_context}}. Pain quality/severity/pattern: {{pain_quality_pattern}}. Aggravating/relieving factors: {{aggravating_relieving}}.\n\nFunction/goals: {{functional_limitations}}. Condition-specific prompts/findings: {{condition_specific_questions}}.\n\nPrior treatment response: {{prior_treatments}}. Current medications/relevant issues: {{current_medications}}. Diagnostics reviewed: {{imaging_labs_tests}}. Safety/red flags/neuro/systemic screen: {{red_flags_neuro_screen}}. Sleep/mood/psychosocial context: {{psychosocial_sleep_mood}}. Preferences/affordability/priorities: {{patient_preferences_affordability}}.\n\nHistory-based impression/plan: {{history_impression_plan}} {{history_followup_phrase}}", "applicable_procedure_ids": ["trigger_point_injections", "intercostal_nerve_block_us", "ilioinguinal_nerve_block_us", "ketamine_infusion_chronic_pain"], "navigator": {"region": "General / multisite pain", "condition": "Chronic post-surgical pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_chronic_post_surgical_pain", "title": "Physical exam - Chronic post-surgical pain", "region": "Condition exam", "family": "Physical Exam", "conditions": ["Chronic post-surgical pain"], "condition_tags": "Chronic post-surgical pain", "template_sheet": "PE Chronic postsurgical pain", "sheet_name": "PE Chronic postsurgical pain", "form_type": "Physical Exam", "category": "Physical Exam", "status": "Added v0.5 condition-specific physical exam form", "defaults": {"condition_focus": "Chronic post-surgical pain", "condition_specific_exam": "Surgery type, scar/allodynia, neuropathic features, functional impact.", "exam_safety_phrase": "Exam findings were interpreted in context of history, imaging, medication profile, and patient-specific procedural risk."}, "fields": [{"section": "Header", "key": "clinician_name", "label": "Clinician", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Clinic-wide clinician default; edit if different."}, {"section": "Header", "key": "encounter_date", "label": "Encounter date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only date."}, {"section": "Header", "key": "condition_focus", "label": "Condition focus", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Per-form condition focus."}, {"section": "General", "key": "general_appearance_vitals", "label": "General appearance / relevant vitals", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Observation", "key": "gait_posture_movement", "label": "Gait, posture, and movement observation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Inspection", "key": "inspection_findings", "label": "Inspection", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Palpation", "key": "palpation_findings", "label": "Palpation / tenderness / trigger points", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "ROM", "key": "range_of_motion", "label": "Range of motion", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Neuro", "key": "strength_sensation_reflexes", "label": "Strength, sensation, reflexes / neurovascular status", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Provocation", "key": "condition_specific_exam", "label": "Condition-specific exam maneuvers", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Per-form prompts; replace with actual exam findings."}, {"section": "Safety", "key": "red_flag_exam_findings", "label": "Red-flag exam findings / escalation triggers", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Procedure planning", "key": "procedural_target_assessment", "label": "Procedure target assessment and image correlation", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}, {"section": "Assessment", "key": "exam_safety_phrase", "label": "Exam safety/context phrase", "default_layer": "Global Default", "input_type": "textarea", "required": false, "options": "", "help": "Global default; edit if needed."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan / next steps", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only."}], "template": "Physical examination template: Chronic post-surgical pain\nClinician: {{clinician_name}}. Date: {{encounter_date}}.\n\nGeneral/vitals: {{general_appearance_vitals}}. Gait/posture/movement: {{gait_posture_movement}}. Inspection: {{inspection_findings}}. Palpation: {{palpation_findings}}. ROM: {{range_of_motion}}. Strength/sensation/reflexes/neurovascular: {{strength_sensation_reflexes}}.\n\nCondition-specific maneuvers/findings: {{condition_specific_exam}}. Red flags/escalation findings: {{red_flag_exam_findings}}. Procedural target/image correlation: {{procedural_target_assessment}}.\n\nPain generator impression: {{pain_generator_impression}}. {{exam_safety_phrase}} Plan: {{exam_plan}}", "applicable_procedure_ids": ["trigger_point_injections", "intercostal_nerve_block_us", "ilioinguinal_nerve_block_us", "ketamine_infusion_chronic_pain"], "navigator": {"region": "General / multisite pain", "condition": "Chronic post-surgical pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_headache_cranial_neuralgia", "form_type": "History", "title": "History - Headache / cranial neuralgia", "family": "History", "category": "History", "condition_tags": "Headache / cranial neuralgia", "template_sheet": "Hx_headache_cranial_neuralgia", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Headache / cranial neuralgia\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "Cervical spine / head", "condition": "Headache / cranial neuralgia", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_headache_cranial_neuralgia", "form_type": "Physical Exam", "title": "Physical Exam - Headache / cranial neuralgia", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Headache / cranial neuralgia", "template_sheet": "PE_headache_cranial_neuralgia", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Headache / cranial neuralgia\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "Cervical spine / head", "condition": "Headache / cranial neuralgia", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_trigeminal_neuralgia_facial_pain", "form_type": "History", "title": "History - Trigeminal neuralgia / facial neuropathic pain", "family": "History", "category": "History", "condition_tags": "Trigeminal neuralgia / facial neuropathic pain", "template_sheet": "Hx_trigeminal_neuralgia_facial_", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Trigeminal neuralgia / facial neuropathic pain\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Trigeminal neuralgia / facial neuropathic pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_trigeminal_neuralgia_facial_pain", "form_type": "Physical Exam", "title": "Physical Exam - Trigeminal neuralgia / facial neuropathic pain", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Trigeminal neuralgia / facial neuropathic pain", "template_sheet": "PE_trigeminal_neuralgia_facial_", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Trigeminal neuralgia / facial neuropathic pain\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Trigeminal neuralgia / facial neuropathic pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_post_mastectomy_chest_wall_pain", "form_type": "History", "title": "History - Post-mastectomy / post-thoracotomy chest wall pain", "family": "History", "category": "History", "condition_tags": "Post-mastectomy / post-thoracotomy chest wall pain", "template_sheet": "Hx_post_mastectomy_chest_wall_p", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Post-mastectomy / post-thoracotomy chest wall pain\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "Thoracic spine / chest wall", "condition": "Post-mastectomy / post-thoracotomy chest wall pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_post_mastectomy_chest_wall_pain", "form_type": "Physical Exam", "title": "Physical Exam - Post-mastectomy / post-thoracotomy chest wall pain", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Post-mastectomy / post-thoracotomy chest wall pain", "template_sheet": "PE_post_mastectomy_chest_wall_p", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Post-mastectomy / post-thoracotomy chest wall pain\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "Thoracic spine / chest wall", "condition": "Post-mastectomy / post-thoracotomy chest wall pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_meralgia_paresthetica", "form_type": "History", "title": "History - Meralgia paresthetica / lateral femoral cutaneous neuralgia", "family": "History", "category": "History", "condition_tags": "Meralgia paresthetica / lateral femoral cutaneous neuralgia", "template_sheet": "Hx_meralgia_paresthetica", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Meralgia paresthetica / lateral femoral cutaneous neuralgia\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Meralgia paresthetica / lateral femoral cutaneous neuralgia", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_meralgia_paresthetica", "form_type": "Physical Exam", "title": "Physical Exam - Meralgia paresthetica / lateral femoral cutaneous neuralgia", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Meralgia paresthetica / lateral femoral cutaneous neuralgia", "template_sheet": "PE_meralgia_paresthetica", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Meralgia paresthetica / lateral femoral cutaneous neuralgia\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Meralgia paresthetica / lateral femoral cutaneous neuralgia", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_tarsal_tunnel_tibial_neuralgia", "form_type": "History", "title": "History - Tarsal tunnel syndrome / tibial neuralgia", "family": "History", "category": "History", "condition_tags": "Tarsal tunnel syndrome / tibial neuralgia", "template_sheet": "Hx_tarsal_tunnel_tibial_neuralg", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Tarsal tunnel syndrome / tibial neuralgia\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "Foot / ankle", "condition": "Tarsal tunnel syndrome / tibial neuralgia", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_tarsal_tunnel_tibial_neuralgia", "form_type": "Physical Exam", "title": "Physical Exam - Tarsal tunnel syndrome / tibial neuralgia", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Tarsal tunnel syndrome / tibial neuralgia", "template_sheet": "PE_tarsal_tunnel_tibial_neuralg", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Tarsal tunnel syndrome / tibial neuralgia\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "Foot / ankle", "condition": "Tarsal tunnel syndrome / tibial neuralgia", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_peroneal_neuralgia", "form_type": "History", "title": "History - Common peroneal neuralgia / lateral leg neuropathic pain", "family": "History", "category": "History", "condition_tags": "Common peroneal neuralgia / lateral leg neuropathic pain", "template_sheet": "Hx_peroneal_neuralgia", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Common peroneal neuralgia / lateral leg neuropathic pain\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Common peroneal neuralgia / lateral leg neuropathic pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_peroneal_neuralgia", "form_type": "Physical Exam", "title": "Physical Exam - Common peroneal neuralgia / lateral leg neuropathic pain", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Common peroneal neuralgia / lateral leg neuropathic pain", "template_sheet": "PE_peroneal_neuralgia", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Common peroneal neuralgia / lateral leg neuropathic pain\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Common peroneal neuralgia / lateral leg neuropathic pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_saphenous_neuralgia", "form_type": "History", "title": "History - Saphenous neuralgia / medial knee neuropathic pain", "family": "History", "category": "History", "condition_tags": "Saphenous neuralgia / medial knee neuropathic pain", "template_sheet": "Hx_saphenous_neuralgia", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Saphenous neuralgia / medial knee neuropathic pain\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "Knee", "condition": "Saphenous neuralgia / medial knee neuropathic pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_saphenous_neuralgia", "form_type": "Physical Exam", "title": "Physical Exam - Saphenous neuralgia / medial knee neuropathic pain", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Saphenous neuralgia / medial knee neuropathic pain", "template_sheet": "PE_saphenous_neuralgia", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Saphenous neuralgia / medial knee neuropathic pain\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "Knee", "condition": "Saphenous neuralgia / medial knee neuropathic pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_obturator_neuralgia", "form_type": "History", "title": "History - Obturator neuralgia / medial groin pain", "family": "History", "category": "History", "condition_tags": "Obturator neuralgia / medial groin pain", "template_sheet": "Hx_obturator_neuralgia", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Obturator neuralgia / medial groin pain\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Obturator neuralgia / medial groin pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_obturator_neuralgia", "form_type": "Physical Exam", "title": "Physical Exam - Obturator neuralgia / medial groin pain", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Obturator neuralgia / medial groin pain", "template_sheet": "PE_obturator_neuralgia", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Obturator neuralgia / medial groin pain\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Obturator neuralgia / medial groin pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_femoral_neuralgia", "form_type": "History", "title": "History - Femoral neuralgia / anterior thigh neuropathic pain", "family": "History", "category": "History", "condition_tags": "Femoral neuralgia / anterior thigh neuropathic pain", "template_sheet": "Hx_femoral_neuralgia", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Femoral neuralgia / anterior thigh neuropathic pain\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Femoral neuralgia / anterior thigh neuropathic pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_femoral_neuralgia", "form_type": "Physical Exam", "title": "Physical Exam - Femoral neuralgia / anterior thigh neuropathic pain", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Femoral neuralgia / anterior thigh neuropathic pain", "template_sheet": "PE_femoral_neuralgia", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Femoral neuralgia / anterior thigh neuropathic pain\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Femoral neuralgia / anterior thigh neuropathic pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_vertebrogenic_low_back_pain", "form_type": "History", "title": "History - Vertebrogenic low back pain / Modic change-associated pain", "family": "History", "category": "History", "condition_tags": "Vertebrogenic low back pain / Modic change-associated pain", "template_sheet": "Hx_vertebrogenic_low_back_pain", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Vertebrogenic low back pain / Modic change-associated pain\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "Lumbar spine", "condition": "Vertebrogenic low back pain / Modic change-associated pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_vertebrogenic_low_back_pain", "form_type": "Physical Exam", "title": "Physical Exam - Vertebrogenic low back pain / Modic change-associated pain", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Vertebrogenic low back pain / Modic change-associated pain", "template_sheet": "PE_vertebrogenic_low_back_pain", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Vertebrogenic low back pain / Modic change-associated pain\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "Lumbar spine", "condition": "Vertebrogenic low back pain / Modic change-associated pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_failed_back_surgery_syndrome", "form_type": "History", "title": "History - Failed back surgery syndrome / persistent spinal pain syndrome", "family": "History", "category": "History", "condition_tags": "Failed back surgery syndrome / persistent spinal pain syndrome", "template_sheet": "Hx_failed_back_surgery_syndrome", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Failed back surgery syndrome / persistent spinal pain syndrome\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Failed back surgery syndrome / persistent spinal pain syndrome", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_failed_back_surgery_syndrome", "form_type": "Physical Exam", "title": "Physical Exam - Failed back surgery syndrome / persistent spinal pain syndrome", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Failed back surgery syndrome / persistent spinal pain syndrome", "template_sheet": "PE_failed_back_surgery_syndrome", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Failed back surgery syndrome / persistent spinal pain syndrome\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Failed back surgery syndrome / persistent spinal pain syndrome", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_phantom_limb_stump_pain", "form_type": "History", "title": "History - Phantom limb pain / stump pain", "family": "History", "category": "History", "condition_tags": "Phantom limb pain / stump pain", "template_sheet": "Hx_phantom_limb_stump_pain", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Phantom limb pain / stump pain\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Phantom limb pain / stump pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_phantom_limb_stump_pain", "form_type": "Physical Exam", "title": "Physical Exam - Phantom limb pain / stump pain", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Phantom limb pain / stump pain", "template_sheet": "PE_phantom_limb_stump_pain", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Phantom limb pain / stump pain\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Phantom limb pain / stump pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_post_herniorrhaphy_groin_pain", "form_type": "History", "title": "History - Post-herniorrhaphy groin pain", "family": "History", "category": "History", "condition_tags": "Post-herniorrhaphy groin pain", "template_sheet": "Hx_post_herniorrhaphy_groin_pai", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Post-herniorrhaphy groin pain\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Post-herniorrhaphy groin pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_post_herniorrhaphy_groin_pain", "form_type": "Physical Exam", "title": "Physical Exam - Post-herniorrhaphy groin pain", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Post-herniorrhaphy groin pain", "template_sheet": "PE_post_herniorrhaphy_groin_pai", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Post-herniorrhaphy groin pain\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Post-herniorrhaphy groin pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_abdominal_wall_pain", "form_type": "History", "title": "History - Abdominal wall pain / ACNES / post-surgical abdominal wall pain", "family": "History", "category": "History", "condition_tags": "Abdominal wall pain / ACNES / post-surgical abdominal wall pain", "template_sheet": "Hx_abdominal_wall_pain", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Abdominal wall pain / ACNES / post-surgical abdominal wall pain\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Abdominal wall pain / ACNES / post-surgical abdominal wall pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_abdominal_wall_pain", "form_type": "Physical Exam", "title": "Physical Exam - Abdominal wall pain / ACNES / post-surgical abdominal wall pain", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Abdominal wall pain / ACNES / post-surgical abdominal wall pain", "template_sheet": "PE_abdominal_wall_pain", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Abdominal wall pain / ACNES / post-surgical abdominal wall pain\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Abdominal wall pain / ACNES / post-surgical abdominal wall pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_sympathetically_maintained_pain", "form_type": "History", "title": "History - Sympathetically maintained pain", "family": "History", "category": "History", "condition_tags": "Sympathetically maintained pain", "template_sheet": "Hx_sympathetically_maintained_p", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Sympathetically maintained pain\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Sympathetically maintained pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_sympathetically_maintained_pain", "form_type": "Physical Exam", "title": "Physical Exam - Sympathetically maintained pain", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Sympathetically maintained pain", "template_sheet": "PE_sympathetically_maintained_p", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Sympathetically maintained pain\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "General / multisite pain", "condition": "Sympathetically maintained pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_flank_pain_regional_pain", "form_type": "History", "title": "History - Flank pain / thoracolumbar regional pain", "family": "History", "category": "History", "condition_tags": "Flank pain / thoracolumbar regional pain", "template_sheet": "Hx_flank_pain_regional_pain", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Flank pain / thoracolumbar regional pain\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "Lumbar spine", "condition": "Flank pain / thoracolumbar regional pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_flank_pain_regional_pain", "form_type": "Physical Exam", "title": "Physical Exam - Flank pain / thoracolumbar regional pain", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Flank pain / thoracolumbar regional pain", "template_sheet": "PE_flank_pain_regional_pain", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Flank pain / thoracolumbar regional pain\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "Lumbar spine", "condition": "Flank pain / thoracolumbar regional pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "hist_pelvic_visceral_pain", "form_type": "History", "title": "History - Chronic pelvic / visceral pelvic pain", "family": "History", "category": "History", "condition_tags": "Chronic pelvic / visceral pelvic pain", "template_sheet": "Hx_pelvic_visceral_pain", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "History", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused condition-specific history."}, {"section": "History", "key": "presenting_complaint", "label": "Presenting complaint / pain problem", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Current pain complaint and chronology."}, {"section": "History", "key": "pain_location_distribution", "label": "Pain location / distribution", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Map region, radiation, neuropathic distribution, and focal tenderness."}, {"section": "History", "key": "functional_limitations", "label": "Function / goals", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Functional impact and patient goals."}, {"section": "History", "key": "prior_treatments", "label": "Prior treatments / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Medication, therapy, injections, surgery, and response."}, {"section": "History", "key": "current_medications", "label": "Current medications / anticoagulants", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Include relevant anticoagulants, antiplatelets, allergy considerations."}, {"section": "History", "key": "red_flags_neuro_screen", "label": "Red flags / neurologic screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Safety screen relevant to procedure planning."}, {"section": "History", "key": "imaging_labs_tests", "label": "Imaging / tests reviewed", "default_layer": "No Default", "input_type": "textarea", "required": false, "options": "", "help": "Imaging, EMG/NCS, labs, or other investigations."}, {"section": "Plan", "key": "history_impression_plan", "label": "History impression / plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Working diagnosis and plan."}], "narrative_template": "History - Chronic pelvic / visceral pelvic pain\n\nCondition focus: {{condition_focus}}\nPresenting complaint: {{presenting_complaint}}\nPain distribution: {{pain_location_distribution}}\nFunction/goals: {{functional_limitations}}\nPrior treatments: {{prior_treatments}}\nMedications/safety: {{current_medications}}\nRed flags/neuro screen: {{red_flags_neuro_screen}}\nImaging/tests: {{imaging_labs_tests}}\nImpression/plan: {{history_impression_plan}}", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Chronic pelvic / visceral pelvic pain", "guidance_options": ["N/A"], "intervention_type": "History", "procedure_group": "History"}}, {"form_id": "exam_pelvic_visceral_pain", "form_type": "Physical Exam", "title": "Physical Exam - Chronic pelvic / visceral pelvic pain", "family": "Physical Exam", "category": "Physical Exam", "condition_tags": "Chronic pelvic / visceral pelvic pain", "template_sheet": "PE_pelvic_visceral_pain", "status": "v0.8 generated chronic-pain condition shell - physician review required", "fields": [{"section": "Exam", "key": "condition_focus", "label": "Condition focus", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Focused exam context."}, {"section": "Exam", "key": "inspection_function", "label": "Inspection / function", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Inspection, gait/use, posture, functional provocation."}, {"section": "Exam", "key": "palpation_findings", "label": "Palpation / tenderness", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Tenderness, trigger points, enthesis, joint line, nerve course."}, {"section": "Exam", "key": "range_strength_neuro", "label": "Range / strength / neurologic findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "ROM, strength, sensory/reflex or regional neurologic findings."}, {"section": "Exam", "key": "condition_specific_exam", "label": "Condition-specific provocative tests", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Special tests relevant to target selection."}, {"section": "Exam", "key": "red_flag_exam_findings", "label": "Red flag / safety findings", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Findings that alter procedure risk or urgency."}, {"section": "Assessment", "key": "pain_generator_impression", "label": "Pain generator impression", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Most likely pain generator(s)."}, {"section": "Assessment", "key": "procedural_target_assessment", "label": "Procedural target assessment", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Proposed target(s), guidance needs, and anatomy considerations."}, {"section": "Plan", "key": "exam_plan", "label": "Exam-based plan", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Plan after exam."}], "narrative_template": "Physical Exam - Chronic pelvic / visceral pelvic pain\n\nCondition focus: {{condition_focus}}\nInspection/function: {{inspection_function}}\nPalpation: {{palpation_findings}}\nROM/strength/neuro: {{range_strength_neuro}}\nCondition-specific exam: {{condition_specific_exam}}\nRed flag findings: {{red_flag_exam_findings}}\nPain generator impression: {{pain_generator_impression}}\nProcedural target assessment: {{procedural_target_assessment}}\nPlan: {{exam_plan}}", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Chronic pelvic / visceral pelvic pain", "guidance_options": ["N/A"], "intervention_type": "Physical Exam", "procedure_group": "Physical Exam"}}, {"form_id": "plantar_fascia_steroid_us", "form_type": "Procedure", "title": "Plantar fascia corticosteroid injection - ultrasound-guided", "family": "Plantar fascia injections", "category": "Plantar fascia injections", "condition_tags": "Plantar fasciopathy; Heel pain", "conditions": ["Plantar fasciopathy", "Heel pain"], "template_sheet": "plantar_fascia_steroid_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine or prone with foot positioned to expose medial heel", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Medial in-plane approach avoiding plantar fat pad", "target": "Plantar fascia origin/perifascial target region", "needle": "Echogenic needle selected by proceduralist", "injectate_product": "Corticosteroid with/without local anesthetic as selected; verify product and DIN", "dose_volume": "Small-volume steroid/local anesthetic injectate", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Corticosteroid with/without local anesthetic as selected; verify product and DIN", "next_procedure_dose": "Small-volume steroid/local anesthetic injectate", "next_procedure_technique": "Ultrasound-guided; Medial in-plane approach avoiding plantar fat pad; Plantar fascia origin/perifascial target region; Echogenic needle selected by proceduralist", "next_procedure_patient_position": "Supine or prone with foot positioned to expose medial heel", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Plantar fascia corticosteroid injection - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Foot / ankle", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Plantar fascia injections", "condition": "Plantar fasciopathy"}}, {"form_id": "plantar_fascia_prp_us", "form_type": "Procedure", "title": "Plantar fascia PRP injection / fenestration - ultrasound-guided", "family": "Plantar fascia injections", "category": "Plantar fascia injections", "condition_tags": "Plantar fasciopathy; Heel pain", "conditions": ["Plantar fasciopathy", "Heel pain"], "template_sheet": "plantar_fascia_prp_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine or prone with foot positioned to expose medial heel", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Medial in-plane approach with fenestration as selected", "target": "Degenerative plantar fascia origin / perifascial target", "needle": "Echogenic needle selected by proceduralist", "injectate_product": "Autologous PRP prepared using clinic-verified system", "dose_volume": "PRP volume/yield documented from current preparation", "diluent_anesthetic": "Autologous PRP only unless physician documents adjunct.", "next_procedure_medication_choice": "Autologous PRP prepared using clinic-verified system", "next_procedure_dose": "PRP volume/yield documented from current preparation", "next_procedure_technique": "Ultrasound-guided; Medial in-plane approach with fenestration as selected; Degenerative plantar fascia origin / perifascial target; Echogenic needle selected by proceduralist", "next_procedure_patient_position": "Supine or prone with foot positioned to expose medial heel", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Plantar fascia PRP injection / fenestration - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Foot / ankle", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regenerative injection", "procedure_group": "Plantar fascia injections", "condition": "Plantar fasciopathy"}}, {"form_id": "plantar_fascia_prolo_us", "form_type": "Procedure", "title": "Plantar fascia prolotherapy - ultrasound-guided or landmark-guided", "family": "Plantar fascia injections", "category": "Plantar fascia injections", "condition_tags": "Plantar fasciopathy; Heel pain", "conditions": ["Plantar fasciopathy", "Heel pain"], "template_sheet": "plantar_fascia_prolo_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine or prone with foot positioned to expose medial heel", "guidance": "Ultrasound-guided where indicated; landmark-guided for superficial enthesis targeting as appropriate", "guidance_phrase": "Ultrasound guidance and/or landmark guidance was used according to the selected target, depth, and safety considerations. Relevant anatomy and needle path were documented as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Medial approach with enthesis/perifascial targeting", "target": "Plantar fascia origin/enthesis and tender perifascial points", "needle": "Needle selected by proceduralist", "injectate_product": "Dextrose prolotherapy solution/local anesthetic mix per clinic protocol; verify products", "dose_volume": "Concentration and volume documented by site", "diluent_anesthetic": "Dextrose/local anesthetic solution per clinic protocol; concentration documented.", "next_procedure_medication_choice": "Dextrose prolotherapy solution/local anesthetic mix per clinic protocol; verify products", "next_procedure_dose": "Concentration and volume documented by site", "next_procedure_technique": "Ultrasound-guided where indicated; landmark-guided for superficial enthesis targeting as appropriate; Medial approach with enthesis/perifascial targeting; Plantar fascia origin/enthesis and tender perifascial points; Needle selected by proceduralist", "next_procedure_patient_position": "Supine or prone with foot positioned to expose medial heel", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Plantar fascia prolotherapy - ultrasound-guided or landmark-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Foot / ankle", "guidance_options": ["Ultrasound-guided", "Landmark-guided"], "intervention_type": "Regenerative injection", "procedure_group": "Plantar fascia injections", "condition": "Plantar fasciopathy"}}, {"form_id": "ilioinguinal_iliohypogastric_block_us", "form_type": "Procedure", "title": "Ilioinguinal / iliohypogastric nerve block - ultrasound-guided", "family": "Abdominal wall nerve blocks", "category": "Abdominal wall nerve blocks", "condition_tags": "Ilioinguinal neuralgia; Iliohypogastric neuralgia; Post-herniorrhaphy pain", "conditions": ["Ilioinguinal neuralgia", "Iliohypogastric neuralgia", "Post-herniorrhaphy pain"], "template_sheet": "ilioinguinal_iliohypogastric_bl", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine with lower abdomen exposed", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane approach in lower abdominal wall", "target": "Fascial plane between internal oblique and transversus abdominis containing ilioinguinal/iliohypogastric nerves", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid as selected; verify products/DIN", "dose_volume": "Volume/concentration selected within safety limits", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify products/DIN", "next_procedure_dose": "Volume/concentration selected within safety limits", "next_procedure_technique": "Ultrasound-guided; In-plane approach in lower abdominal wall; Fascial plane between internal oblique and transversus abdominis containing ilioinguinal/iliohypogastric nerves; Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Supine with lower abdomen exposed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Ilioinguinal / iliohypogastric nerve block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Abdomen / pelvis", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Peripheral nerve block", "procedure_group": "Abdominal wall nerve blocks", "condition": "Ilioinguinal/iliohypogastric/genitofemoral neuralgia; Chronic post-surgical pain; Post-herniorrhaphy groin pain; Abdominal wall pain / ACNES / post-surgical abdominal wall pain"}}, {"form_id": "genitofemoral_block_us", "form_type": "Procedure", "title": "Genitofemoral nerve block - ultrasound-guided", "family": "Abdominal wall nerve blocks", "category": "Abdominal wall nerve blocks", "condition_tags": "Genitofemoral neuralgia; Groin neuralgia; Post-surgical groin pain", "conditions": ["Genitofemoral neuralgia", "Groin neuralgia", "Post-surgical groin pain"], "template_sheet": "genitofemoral_block_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine with target region exposed", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Ultrasound-guided branch-specific approach", "target": "Genitofemoral nerve target region according to branch/site selected", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid as selected; verify products/DIN", "dose_volume": "Small-volume perineural injectate selected by physician", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify products/DIN", "next_procedure_dose": "Small-volume perineural injectate selected by physician", "next_procedure_technique": "Ultrasound-guided; Ultrasound-guided branch-specific approach; Genitofemoral nerve target region according to branch/site selected; Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Supine with target region exposed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Genitofemoral nerve block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Abdomen / pelvis", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Peripheral nerve block", "procedure_group": "Abdominal wall nerve blocks", "condition": "Ilioinguinal/iliohypogastric/genitofemoral neuralgia; Chronic post-surgical pain; Post-herniorrhaphy groin pain; Abdominal wall pain / ACNES / post-surgical abdominal wall pain"}}, {"form_id": "lateral_femoral_cutaneous_block_us", "form_type": "Procedure", "title": "Lateral femoral cutaneous nerve block - ultrasound-guided", "family": "Lower limb peripheral nerve blocks", "category": "Lower limb peripheral nerve blocks", "condition_tags": "Meralgia paresthetica; Lateral femoral cutaneous neuralgia", "conditions": ["Meralgia paresthetica", "Lateral femoral cutaneous neuralgia"], "template_sheet": "lateral_femoral_cutaneous_block", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane approach around nerve target", "target": "Lateral femoral cutaneous nerve near ASIS/inguinal ligament region", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid as selected; verify products/DIN", "dose_volume": "Low-volume perineural injectate", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify products/DIN", "next_procedure_dose": "Low-volume perineural injectate", "next_procedure_technique": "Ultrasound-guided; In-plane approach around nerve target; Lateral femoral cutaneous nerve near ASIS/inguinal ligament region; Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Supine", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Lateral femoral cutaneous nerve block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Hip / thigh", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Peripheral nerve block", "procedure_group": "Lower limb peripheral nerve blocks", "condition": "Peripheral neuropathic pain / post-herpetic neuralgia; Meralgia paresthetica / lateral femoral cutaneous neuralgia"}}, {"form_id": "saphenous_adductor_canal_block_us", "form_type": "Procedure", "title": "Saphenous nerve / adductor canal block - ultrasound-guided", "family": "Lower limb peripheral nerve blocks", "category": "Lower limb peripheral nerve blocks", "condition_tags": "Medial knee pain; Saphenous neuralgia; Chronic knee pain", "conditions": ["Medial knee pain", "Saphenous neuralgia", "Chronic knee pain"], "template_sheet": "saphenous_adductor_canal_block_", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane approach to adductor canal/saphenous nerve region", "target": "Saphenous nerve/adductor canal target region", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid as selected; verify products/DIN", "dose_volume": "Volume/concentration selected within safety limits", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify products/DIN", "next_procedure_dose": "Volume/concentration selected within safety limits", "next_procedure_technique": "Ultrasound-guided; In-plane approach to adductor canal/saphenous nerve region; Saphenous nerve/adductor canal target region; Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Supine", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Saphenous nerve / adductor canal block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Knee / thigh", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Peripheral nerve block", "procedure_group": "Lower limb peripheral nerve blocks", "condition": "Knee osteoarthritis / chronic knee pain; Peripheral neuropathic pain / post-herpetic neuralgia; Saphenous neuralgia / medial knee neuropathic pain"}}, {"form_id": "peroneal_nerve_block_us", "form_type": "Procedure", "title": "Common peroneal nerve block - ultrasound-guided", "family": "Lower limb peripheral nerve blocks", "category": "Lower limb peripheral nerve blocks", "condition_tags": "Peroneal neuralgia; Lateral leg neuropathic pain", "conditions": ["Peroneal neuralgia", "Lateral leg neuropathic pain"], "template_sheet": "peroneal_nerve_block_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine or lateral", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane perineural approach avoiding intraneural injection", "target": "Common peroneal nerve target region near fibular head or selected site", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid as selected; verify products/DIN", "dose_volume": "Low-volume perineural injectate", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify products/DIN", "next_procedure_dose": "Low-volume perineural injectate", "next_procedure_technique": "Ultrasound-guided; In-plane perineural approach avoiding intraneural injection; Common peroneal nerve target region near fibular head or selected site; Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Supine or lateral", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Common peroneal nerve block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Knee / leg", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Peripheral nerve block", "procedure_group": "Lower limb peripheral nerve blocks", "condition": "Peripheral neuropathic pain / post-herpetic neuralgia; Common peroneal neuralgia / lateral leg neuropathic pain"}}, {"form_id": "tibial_nerve_block_us", "form_type": "Procedure", "title": "Posterior tibial nerve block - ultrasound-guided", "family": "Lower limb peripheral nerve blocks", "category": "Lower limb peripheral nerve blocks", "condition_tags": "Tibial neuralgia; Tarsal tunnel syndrome; Foot neuropathic pain", "conditions": ["Tibial neuralgia", "Tarsal tunnel syndrome", "Foot neuropathic pain"], "template_sheet": "tibial_nerve_block_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine or prone with medial ankle accessible", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane perineural approach avoiding intraneural injection", "target": "Posterior tibial nerve target region", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid as selected; verify products/DIN", "dose_volume": "Low-volume perineural injectate", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify products/DIN", "next_procedure_dose": "Low-volume perineural injectate", "next_procedure_technique": "Ultrasound-guided; In-plane perineural approach avoiding intraneural injection; Posterior tibial nerve target region; Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Supine or prone with medial ankle accessible", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Posterior tibial nerve block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Foot / ankle", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Peripheral nerve block", "procedure_group": "Lower limb peripheral nerve blocks", "condition": "Morton neuroma / forefoot neuralgia; Peripheral neuropathic pain / post-herpetic neuralgia; Tarsal tunnel syndrome / tibial neuralgia"}}, {"form_id": "hip_ha_us", "form_type": "Procedure", "title": "Hip intra-articular hyaluronic acid injection - ultrasound-guided", "family": "Hip joint injections", "category": "Hip joint injections", "condition_tags": "Hip osteoarthritis; Chronic groin pain", "conditions": ["Hip osteoarthritis", "Chronic groin pain"], "template_sheet": "hip_ha_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Anterior oblique in-plane approach", "target": "Femoral head-neck junction / anterior hip joint recess", "needle": "Spinal or echogenic needle sized to depth", "injectate_product": "Hyaluronic acid product selected by physician; verify device/licence/product details", "dose_volume": "Product-specific volume/dose", "diluent_anesthetic": "Product-specific hyaluronic acid preparation; no additional mix unless documented.", "next_procedure_medication_choice": "Hyaluronic acid product selected by physician; verify device/licence/product details", "next_procedure_dose": "Product-specific volume/dose", "next_procedure_technique": "Ultrasound-guided, in-plane; Anterior oblique in-plane approach; Femoral head-neck junction / anterior hip joint recess; Spinal or echogenic needle sized to depth", "next_procedure_patient_position": "Supine", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Hip intra-articular hyaluronic acid injection - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Hip / pelvis", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Viscosupplementation", "procedure_group": "Hip joint injections", "condition": "Hip osteoarthritis / chronic groin pain"}}, {"form_id": "hip_periarticular_prolo_us", "form_type": "Procedure", "title": "Hip periarticular / capsular-ligament prolotherapy - ultrasound-guided", "family": "Hip periarticular injections", "category": "Hip periarticular injections", "condition_tags": "Hip osteoarthritis; Periarticular hip pain", "conditions": ["Hip osteoarthritis", "Periarticular hip pain"], "template_sheet": "hip_periarticular_prolo_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine or lateral depending on targets", "guidance": "Ultrasound-guided where indicated plus palpation-guided superficial enthesis targeting as appropriate", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Site-specific approach to tender/sonographic targets", "target": "Hip capsular/ligamentous/enthesis targets selected by physician", "needle": "Needle selected by proceduralist", "injectate_product": "Dextrose prolotherapy solution/local anesthetic mix per clinic protocol; verify products", "dose_volume": "Concentration and volume documented by site", "diluent_anesthetic": "Dextrose/local anesthetic solution per clinic protocol; concentration documented.", "next_procedure_medication_choice": "Dextrose prolotherapy solution/local anesthetic mix per clinic protocol; verify products", "next_procedure_dose": "Concentration and volume documented by site", "next_procedure_technique": "Ultrasound-guided where indicated plus palpation-guided superficial enthesis targeting as appropriate; Site-specific approach to tender/sonographic targets; Hip capsular/ligamentous/enthesis targets selected by physician; Needle selected by proceduralist", "next_procedure_patient_position": "Supine or lateral depending on targets", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Hip periarticular / capsular-ligament prolotherapy - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Hip / pelvis", "guidance_options": ["Ultrasound-guided", "Landmark-guided"], "intervention_type": "Regenerative injection", "procedure_group": "Hip periarticular injections", "condition": "Hip osteoarthritis / chronic groin pain; Greater trochanteric pain syndrome"}}, {"form_id": "greater_trochanter_prp_us", "form_type": "Procedure", "title": "Greater trochanteric / gluteal tendon PRP injection - ultrasound-guided", "family": "Hip periarticular injections", "category": "Hip periarticular injections", "condition_tags": "Greater trochanteric pain syndrome; Gluteal tendinopathy", "conditions": ["Greater trochanteric pain syndrome", "Gluteal tendinopathy"], "template_sheet": "greater_trochanter_prp_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Lateral decubitus or side-lying", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane lateral approach", "target": "Gluteal tendon/peritendinous target and/or trochanteric bursa region", "needle": "Echogenic needle selected by proceduralist", "injectate_product": "Autologous PRP prepared using clinic-verified system", "dose_volume": "PRP volume/yield documented from current preparation", "diluent_anesthetic": "Autologous PRP only unless physician documents adjunct.", "next_procedure_medication_choice": "Autologous PRP prepared using clinic-verified system", "next_procedure_dose": "PRP volume/yield documented from current preparation", "next_procedure_technique": "Ultrasound-guided; In-plane lateral approach; Gluteal tendon/peritendinous target and/or trochanteric bursa region; Echogenic needle selected by proceduralist", "next_procedure_patient_position": "Lateral decubitus or side-lying", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Greater trochanteric / gluteal tendon PRP injection - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Hip / pelvis", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regenerative injection", "procedure_group": "Hip periarticular injections", "condition": "Greater trochanteric pain syndrome"}}, {"form_id": "biceps_tendon_sheath_steroid_us", "form_type": "Procedure", "title": "Long head biceps tendon sheath corticosteroid injection - ultrasound-guided", "family": "Shoulder tendon/bursa injections", "category": "Shoulder tendon/bursa injections", "condition_tags": "Long head biceps tendinopathy; Anterior shoulder pain", "conditions": ["Long head biceps tendinopathy", "Anterior shoulder pain"], "template_sheet": "biceps_tendon_sheath_steroid_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine or seated with shoulder positioned to expose bicipital groove", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane approach to tendon sheath avoiding intratendinous injection", "target": "Long head biceps tendon sheath in bicipital groove", "needle": "Echogenic needle selected by proceduralist", "injectate_product": "Corticosteroid with/without local anesthetic as selected; verify product and DIN", "dose_volume": "Small-volume tendon sheath injectate", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Corticosteroid with/without local anesthetic as selected; verify product and DIN", "next_procedure_dose": "Small-volume tendon sheath injectate", "next_procedure_technique": "Ultrasound-guided, in-plane; In-plane approach to tendon sheath avoiding intratendinous injection; Long head biceps tendon sheath in bicipital groove; Echogenic needle selected by proceduralist", "next_procedure_patient_position": "Supine or seated with shoulder positioned to expose bicipital groove", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Long head biceps tendon sheath corticosteroid injection - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Shoulder", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Shoulder tendon/bursa injections", "condition": "Rotator cuff tendinopathy / subacromial pain; Long head biceps tendinopathy"}}, {"form_id": "shoulder_ha_us", "form_type": "Procedure", "title": "Shoulder glenohumeral hyaluronic acid injection - ultrasound-guided", "family": "Shoulder joint injections", "category": "Shoulder joint injections", "condition_tags": "Shoulder osteoarthritis; Adhesive capsulitis", "conditions": ["Shoulder osteoarthritis", "Adhesive capsulitis"], "template_sheet": "shoulder_ha_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Seated or lateral/prone according to approach", "guidance": "Ultrasound-guided, in-plane", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Posterior or anterior in-plane approach as selected", "target": "Glenohumeral joint recess", "needle": "Spinal or echogenic needle selected by proceduralist", "injectate_product": "Hyaluronic acid product selected by physician; verify device/licence/product details", "dose_volume": "Product-specific volume/dose", "diluent_anesthetic": "Product-specific hyaluronic acid preparation; no additional mix unless documented.", "next_procedure_medication_choice": "Hyaluronic acid product selected by physician; verify device/licence/product details", "next_procedure_dose": "Product-specific volume/dose", "next_procedure_technique": "Ultrasound-guided, in-plane; Posterior or anterior in-plane approach as selected; Glenohumeral joint recess; Spinal or echogenic needle selected by proceduralist", "next_procedure_patient_position": "Seated or lateral/prone according to approach", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Shoulder glenohumeral hyaluronic acid injection - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Shoulder", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Viscosupplementation", "procedure_group": "Shoulder joint injections", "condition": "Shoulder osteoarthritis / adhesive capsulitis"}}, {"form_id": "ankle_prp_us", "form_type": "Procedure", "title": "Tibiotalar ankle joint PRP injection - ultrasound-guided", "family": "Ankle joint injections", "category": "Ankle joint injections", "condition_tags": "Ankle osteoarthritis; Chronic ankle pain", "conditions": ["Ankle osteoarthritis", "Chronic ankle pain"], "template_sheet": "ankle_prp_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine with ankle accessible", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Anterior in-plane or out-of-plane approach according to anatomy", "target": "Tibiotalar joint recess", "needle": "Echogenic needle selected by proceduralist", "injectate_product": "Autologous PRP prepared using clinic-verified system", "dose_volume": "PRP volume/yield documented from current preparation", "diluent_anesthetic": "Autologous PRP only unless physician documents adjunct.", "next_procedure_medication_choice": "Autologous PRP prepared using clinic-verified system", "next_procedure_dose": "PRP volume/yield documented from current preparation", "next_procedure_technique": "Ultrasound-guided; Anterior in-plane or out-of-plane approach according to anatomy; Tibiotalar joint recess; Echogenic needle selected by proceduralist", "next_procedure_patient_position": "Supine with ankle accessible", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Tibiotalar ankle joint PRP injection - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Foot / ankle", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regenerative injection", "procedure_group": "Ankle joint injections", "condition": "Ankle osteoarthritis"}}, {"form_id": "coccygeal_ligament_injection_us", "form_type": "Procedure", "title": "Coccygeal ligament / sacrococcygeal injection - ultrasound-guided or landmark-guided", "family": "Coccyx / ganglion impar region", "category": "Coccyx / ganglion impar region", "condition_tags": "Coccydynia; Sacrococcygeal pain", "conditions": ["Coccydynia", "Sacrococcygeal pain"], "template_sheet": "coccygeal_ligament_injection_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Prone or lateral with coccyx accessible", "guidance": "Ultrasound-guided or landmark-guided according to anatomy and target depth", "guidance_phrase": "Ultrasound guidance and/or landmark guidance was used according to the selected target, depth, and safety considerations. Relevant anatomy and needle path were documented as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Midline or paramedian approach to selected coccygeal target", "target": "Sacrococcygeal joint/ligament or tender coccygeal target", "needle": "Needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid as selected; verify products/DIN", "dose_volume": "Small-volume injectate by target", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify products/DIN", "next_procedure_dose": "Small-volume injectate by target", "next_procedure_technique": "Ultrasound-guided or landmark-guided according to anatomy and target depth; Midline or paramedian approach to selected coccygeal target; Sacrococcygeal joint/ligament or tender coccygeal target; Needle selected by proceduralist", "next_procedure_patient_position": "Prone or lateral with coccyx accessible", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Coccygeal ligament / sacrococcygeal injection - ultrasound-guided or landmark-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / coccyx", "guidance_options": ["Ultrasound-guided", "Landmark-guided"], "intervention_type": "Injection", "procedure_group": "Coccyx / ganglion impar region", "condition": "Coccydynia"}}, {"form_id": "lumbar_interlaminar_esi_us", "form_type": "Procedure", "title": "Lumbar interlaminar epidural steroid injection - ultrasound-assisted / no fluoroscopy", "family": "Epidural steroid injections (ESI)", "category": "Epidural steroid injections (ESI)", "condition_tags": "Lumbar radicular pain; Sciatica; Lumbar spinal stenosis", "conditions": ["Lumbar radicular pain", "Sciatica", "Lumbar spinal stenosis"], "template_sheet": "lumbar_interlaminar_esi_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Sitting or lateral decubitus with lumbar flexion", "guidance": "Ultrasound-assisted; no fluoroscopy", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Midline or paramedian interlaminar approach", "target": "Lumbar epidural space via interlaminar access at documented level", "needle": "Tuohy epidural needle sized to patient habitus and target depth", "injectate_product": "Steroid and preservative-free saline/local anesthetic mix selected by physician; verify route/product/DIN", "dose_volume": "Physician-selected epidural steroid dose and volume", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Steroid and preservative-free saline/local anesthetic mix selected by physician; verify route/product/DIN", "next_procedure_dose": "Physician-selected epidural steroid dose and volume", "next_procedure_technique": "Ultrasound-assisted; no fluoroscopy; Midline or paramedian interlaminar approach; Lumbar epidural space via interlaminar access at documented level; Tuohy epidural needle sized to patient habitus and target depth", "next_procedure_patient_position": "Sitting or lateral decubitus with lumbar flexion", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Lumbar interlaminar epidural steroid injection - ultrasound-assisted / no fluoroscopy\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Lumbar spine", "guidance_options": ["Ultrasound-guided", "Fluoroscopy-guided"], "intervention_type": "Injection", "procedure_group": "Epidural steroid injections (ESI)", "condition": "Lumbar radicular pain / sciatica"}}, {"form_id": "caudal_esi_us", "form_type": "Procedure", "title": "Caudal epidural steroid injection - ultrasound-guided / no fluoroscopy", "family": "Epidural steroid injections (ESI)", "category": "Epidural steroid injections (ESI)", "condition_tags": "Lumbar radicular pain; Sciatica; Lumbar spinal stenosis", "conditions": ["Lumbar radicular pain", "Sciatica", "Lumbar spinal stenosis"], "template_sheet": "caudal_esi_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Prone with sacral hiatus accessible", "guidance": "Ultrasound-guided; no fluoroscopy", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Midline caudal approach through sacral hiatus", "target": "Caudal epidural space through sacrococcygeal ligament", "needle": "22G spinal needle or epidural needle according to depth and protocol", "injectate_product": "Epidural steroid injectate selected by physician; verify route/product/DIN", "dose_volume": "Physician-selected epidural steroid dose/volume", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Epidural steroid injectate selected by physician; verify route/product/DIN", "next_procedure_dose": "Physician-selected epidural steroid dose/volume", "next_procedure_technique": "Ultrasound-guided; no fluoroscopy; Midline caudal approach through sacral hiatus; Caudal epidural space through sacrococcygeal ligament; 22G spinal needle or epidural needle according to depth and protocol", "next_procedure_patient_position": "Prone with sacral hiatus accessible", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating steroid, usual interval is every 3 months or longer unless physician documents a different rationale; reassess indication and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Caudal epidural steroid injection - ultrasound-guided / no fluoroscopy\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Lumbar spine", "guidance_options": ["Ultrasound-guided", "Fluoroscopy-guided"], "intervention_type": "Injection", "procedure_group": "Epidural steroid injections (ESI)", "condition": "Lumbar radicular pain / sciatica; Failed back surgery syndrome / persistent spinal pain syndrome"}}, {"form_id": "lumbar_selective_nerve_root_block_us", "form_type": "Procedure", "title": "Lumbar selective nerve root / periradicular injection - ultrasound-guided", "family": "Selective nerve root blocks (SNRB)", "category": "Selective nerve root blocks (SNRB)", "condition_tags": "Lumbar radicular pain; Sciatica", "conditions": ["Lumbar radicular pain", "Sciatica"], "template_sheet": "lumbar_selective_nerve_root_blo", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Prone or lateral position according to target level and tolerance", "guidance": "Ultrasound-guided; no fluoroscopic contrast confirmation", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Oblique in-plane approach toward documented periradicular/foraminal region", "target": "Periradicular region adjacent to selected lumbar nerve root/foramen as visualized by ultrasound landmarks", "needle": "Spinal or echogenic block needle selected for depth and body habitus", "injectate_product": "Local anesthetic with/without steroid as selected; verify route/product/DIN", "dose_volume": "Low-volume injectate selected per target", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify route/product/DIN", "next_procedure_dose": "Low-volume injectate selected per target", "next_procedure_technique": "Ultrasound-guided; no fluoroscopic contrast confirmation; Oblique in-plane approach toward documented periradicular/foraminal region; Periradicular region adjacent to selected lumbar nerve root/foramen as visualized by ultrasound landmarks; Spinal or echogenic block needle selected for depth and body habitus", "next_procedure_patient_position": "Prone or lateral position according to target level and tolerance", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Lumbar selective nerve root / periradicular injection - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Lumbar spine", "guidance_options": ["Ultrasound-guided", "Fluoroscopy-guided"], "intervention_type": "Injection", "procedure_group": "Selective nerve root blocks (SNRB)", "condition": "Lumbar radicular pain / sciatica"}}, {"form_id": "lumbar_facet_mbb_us", "form_type": "Procedure", "title": "Lumbar medial branch block - ultrasound-guided", "family": "Facet / medial branch blocks", "category": "Facet / medial branch blocks", "condition_tags": "Lumbar facet-mediated pain; Axial low back pain", "conditions": ["Lumbar facet-mediated pain", "Axial low back pain"], "template_sheet": "lumbar_facet_mbb_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Prone with abdomen supported as needed", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Posterior oblique in-plane or out-of-plane approach according to level and visualization", "target": "Lumbar medial branch target region or L5 dorsal ramus target as documented", "needle": "Spinal or echogenic needle sized to target depth", "injectate_product": "Local anesthetic diagnostic block injectate", "dose_volume": "Low-volume local anesthetic per target", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Local anesthetic diagnostic block injectate", "next_procedure_dose": "Low-volume local anesthetic per target", "next_procedure_technique": "Ultrasound-guided; Posterior oblique in-plane or out-of-plane approach according to level and visualization; Lumbar medial branch target region or L5 dorsal ramus target as documented; Spinal or echogenic needle sized to target depth", "next_procedure_patient_position": "Prone with abdomen supported as needed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Lumbar medial branch block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Lumbar spine", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Facet / medial branch blocks", "condition": "Lumbar facet-mediated pain"}}, {"form_id": "lumbar_paravertebral_block_us", "form_type": "Procedure", "title": "Lumbar paravertebral block - ultrasound-guided", "family": "Regional anesthesia / fascial plane blocks", "category": "Regional anesthesia / fascial plane blocks", "condition_tags": "Lumbar pain; Postsurgical lumbar pain", "conditions": ["Lumbar pain", "Postsurgical lumbar pain"], "template_sheet": "lumbar_paravertebral_block_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Prone, lateral, or sitting according to level and tolerance", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane approach to selected lumbar paravertebral region", "target": "Lumbar paravertebral region at documented level(s)", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without adjunct as selected; verify products/DIN", "dose_volume": "Volume/concentration selected within safety limits", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Local anesthetic with/without adjunct as selected; verify products/DIN", "next_procedure_dose": "Volume/concentration selected within safety limits", "next_procedure_technique": "Ultrasound-guided; In-plane approach to selected lumbar paravertebral region; Lumbar paravertebral region at documented level(s); Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Prone, lateral, or sitting according to level and tolerance", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Lumbar paravertebral block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Lumbar spine", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regional block", "procedure_group": "Regional anesthesia / fascial plane blocks", "condition": "Lumbar facet-mediated pain; Lumbar radicular pain / sciatica; Failed back surgery syndrome / persistent spinal pain syndrome"}}, {"form_id": "tlip_block_us", "form_type": "Procedure", "title": "Thoracolumbar interfascial plane (TLIP) block - ultrasound-guided", "family": "Regional anesthesia / fascial plane blocks", "category": "Regional anesthesia / fascial plane blocks", "condition_tags": "Lumbar pain; Postsurgical lumbar pain; Myofascial lumbar pain", "conditions": ["Lumbar pain", "Postsurgical lumbar pain", "Myofascial lumbar pain"], "template_sheet": "tlip_block_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Prone or lateral with lumbar paraspinal region accessible", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane approach between multifidus and longissimus or modified TLIP plane as selected", "target": "Thoracolumbar interfascial plane at documented level(s)", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without adjunct as selected; verify products/DIN", "dose_volume": "Volume/concentration selected within safety limits", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Local anesthetic with/without adjunct as selected; verify products/DIN", "next_procedure_dose": "Volume/concentration selected within safety limits", "next_procedure_technique": "Ultrasound-guided; In-plane approach between multifidus and longissimus or modified TLIP plane as selected; Thoracolumbar interfascial plane at documented level(s); Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Prone or lateral with lumbar paraspinal region accessible", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating nerve ablation/RFA, usual interval is about every year or longer unless physician documents a different rationale; reassess indication, diagnostic response, neurologic status, and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Thoracolumbar interfascial plane (TLIP) block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Lumbar spine", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regional block", "procedure_group": "Regional anesthesia / fascial plane blocks", "condition": "Lumbar facet-mediated pain; Lumbar radicular pain / sciatica; Myofascial pain syndrome; Failed back surgery syndrome / persistent spinal pain syndrome; Flank pain / thoracolumbar regional pain"}}, {"form_id": "cervical_selective_nerve_root_block_us", "form_type": "Procedure", "title": "Cervical selective nerve root / periradicular injection - ultrasound-guided", "family": "Selective nerve root blocks (SNRB)", "category": "Selective nerve root blocks (SNRB)", "condition_tags": "Cervical radicular pain", "conditions": ["Cervical radicular pain"], "template_sheet": "cervical_selective_nerve_root_b", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine or lateral with cervical region exposed", "guidance": "Ultrasound-guided; no fluoroscopic contrast confirmation", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Lateral/anterolateral ultrasound-guided approach according to anatomy and safety", "target": "Cervical nerve root/periradicular target region at documented level", "needle": "Echogenic needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid as selected; verify route/product/DIN", "dose_volume": "Low-volume injectate selected per target", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify route/product/DIN", "next_procedure_dose": "Low-volume injectate selected per target", "next_procedure_technique": "Ultrasound-guided; no fluoroscopic contrast confirmation; Lateral/anterolateral ultrasound-guided approach according to anatomy and safety; Cervical nerve root/periradicular target region at documented level; Echogenic needle selected by proceduralist", "next_procedure_patient_position": "Supine or lateral with cervical region exposed", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Cervical selective nerve root / periradicular injection - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Cervical spine / head", "guidance_options": ["Ultrasound-guided", "Fluoroscopy-guided"], "intervention_type": "Injection", "procedure_group": "Selective nerve root blocks (SNRB)", "condition": "Cervical radicular pain"}}, {"form_id": "cervical_mbb_us", "form_type": "Procedure", "title": "Cervical medial branch block - ultrasound-guided", "family": "Facet / medial branch blocks", "category": "Facet / medial branch blocks", "condition_tags": "Cervical facet-mediated pain; Cervicogenic headache", "conditions": ["Cervical facet-mediated pain", "Cervicogenic headache"], "template_sheet": "cervical_mbb_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Lateral, prone, or seated according to target and tolerance", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane or out-of-plane approach according to level and visualization", "target": "Cervical medial branch target region at documented level(s)", "needle": "Echogenic needle selected by proceduralist", "injectate_product": "Local anesthetic diagnostic block injectate", "dose_volume": "Low-volume local anesthetic per target", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Local anesthetic diagnostic block injectate", "next_procedure_dose": "Low-volume local anesthetic per target", "next_procedure_technique": "Ultrasound-guided; In-plane or out-of-plane approach according to level and visualization; Cervical medial branch target region at documented level(s); Echogenic needle selected by proceduralist", "next_procedure_patient_position": "Lateral, prone, or seated according to target and tolerance", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Cervical medial branch block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Cervical spine / head", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Injection", "procedure_group": "Facet / medial branch blocks", "condition": "Cervical facet-mediated pain; Occipital neuralgia / cervicogenic headache"}}, {"form_id": "cervical_third_occipital_nerve_block_us", "form_type": "Procedure", "title": "Third occipital nerve block - ultrasound-guided", "family": "Headache / occipital procedures", "category": "Headache / occipital procedures", "condition_tags": "Cervicogenic headache; Third occipital neuralgia", "conditions": ["Cervicogenic headache", "Third occipital neuralgia"], "template_sheet": "cervical_third_occipital_nerve_", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Prone, lateral, or seated", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Ultrasound-guided approach according to anatomy", "target": "Third occipital nerve/C2-3 facet target region", "needle": "Echogenic needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid as selected; verify products/DIN", "dose_volume": "Low-volume injectate", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify products/DIN", "next_procedure_dose": "Low-volume injectate", "next_procedure_technique": "Ultrasound-guided; Ultrasound-guided approach according to anatomy; Third occipital nerve/C2-3 facet target region; Echogenic needle selected by proceduralist", "next_procedure_patient_position": "Prone, lateral, or seated", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Third occipital nerve block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Cervical spine / head", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Peripheral nerve block", "procedure_group": "Headache / occipital procedures", "condition": "Cervical facet-mediated pain; Occipital neuralgia / cervicogenic headache; Headache / cranial neuralgia"}}, {"form_id": "occipital_nerve_prf_us", "form_type": "Procedure", "title": "Greater / lesser occipital nerve pulsed radiofrequency - ultrasound-guided", "family": "Headache / occipital procedures", "category": "Headache / occipital procedures", "condition_tags": "Occipital neuralgia; Cervicogenic headache", "conditions": ["Occipital neuralgia", "Cervicogenic headache"], "template_sheet": "occipital_nerve_prf_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Prone, lateral, or seated", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Ultrasound-guided perineural RF cannula placement", "target": "Greater and/or lesser occipital nerve target as documented", "needle": "RF cannula/electrode selected by proceduralist", "injectate_product": "Pulsed RF treatment; local anesthetic as selected", "dose_volume": "PRF settings, duration, sensory testing, and local anesthetic volume documented", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Pulsed RF treatment; local anesthetic as selected", "next_procedure_dose": "PRF settings, duration, sensory testing, and local anesthetic volume documented", "next_procedure_technique": "Ultrasound-guided; Ultrasound-guided perineural RF cannula placement; Greater and/or lesser occipital nerve target as documented; RF cannula/electrode selected by proceduralist", "next_procedure_patient_position": "Prone, lateral, or seated", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating nerve ablation/RFA, usual interval is about every year or longer unless physician documents a different rationale; reassess indication, diagnostic response, neurologic status, and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Greater / lesser occipital nerve pulsed radiofrequency - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Cervical spine / head", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Ablation / PRF", "procedure_group": "Headache / occipital procedures", "condition": "Occipital neuralgia / cervicogenic headache; Headache / cranial neuralgia"}}, {"form_id": "supratrochlear_supraorbital_block_us", "form_type": "Procedure", "title": "Supraorbital / supratrochlear nerve block - ultrasound-guided or landmark-guided", "family": "Headache / cranial nerve blocks", "category": "Headache / cranial nerve blocks", "condition_tags": "Frontal neuralgia; Headache neuralgia", "conditions": ["Frontal neuralgia", "Headache neuralgia"], "template_sheet": "supratrochlear_supraorbital_blo", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine or seated", "guidance": "Ultrasound-guided or landmark-guided according to target and anatomy", "guidance_phrase": "Ultrasound guidance and/or landmark guidance was used according to the selected target, depth, and safety considerations. Relevant anatomy and needle path were documented as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Superficial perineural approach avoiding vascular structures", "target": "Supraorbital and/or supratrochlear nerve region", "needle": "Small-gauge needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid as selected; verify products/DIN", "dose_volume": "Small-volume superficial nerve block injectate", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify products/DIN", "next_procedure_dose": "Small-volume superficial nerve block injectate", "next_procedure_technique": "Ultrasound-guided or landmark-guided according to target and anatomy; Superficial perineural approach avoiding vascular structures; Supraorbital and/or supratrochlear nerve region; Small-gauge needle selected by proceduralist", "next_procedure_patient_position": "Supine or seated", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Supraorbital / supratrochlear nerve block - ultrasound-guided or landmark-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Cervical spine / head", "guidance_options": ["Ultrasound-guided", "Landmark-guided"], "intervention_type": "Peripheral nerve block", "procedure_group": "Headache / cranial nerve blocks", "condition": "Occipital neuralgia / cervicogenic headache; Peripheral neuropathic pain / post-herpetic neuralgia; Headache / cranial neuralgia"}}, {"form_id": "auriculotemporal_block_us", "form_type": "Procedure", "title": "Auriculotemporal nerve block - ultrasound-guided or landmark-guided", "family": "Headache / cranial nerve blocks", "category": "Headache / cranial nerve blocks", "condition_tags": "Auriculotemporal neuralgia; Temporal headache neuralgia", "conditions": ["Auriculotemporal neuralgia", "Temporal headache neuralgia"], "template_sheet": "auriculotemporal_block_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine or seated", "guidance": "Ultrasound-guided or landmark-guided according to target and anatomy", "guidance_phrase": "Ultrasound guidance and/or landmark guidance was used according to the selected target, depth, and safety considerations. Relevant anatomy and needle path were documented as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Superficial perineural approach avoiding temporal vessels", "target": "Auriculotemporal nerve region", "needle": "Small-gauge needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid as selected; verify products/DIN", "dose_volume": "Small-volume superficial nerve block injectate", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify products/DIN", "next_procedure_dose": "Small-volume superficial nerve block injectate", "next_procedure_technique": "Ultrasound-guided or landmark-guided according to target and anatomy; Superficial perineural approach avoiding temporal vessels; Auriculotemporal nerve region; Small-gauge needle selected by proceduralist", "next_procedure_patient_position": "Supine or seated", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Auriculotemporal nerve block - ultrasound-guided or landmark-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Cervical spine / head", "guidance_options": ["Ultrasound-guided", "Landmark-guided"], "intervention_type": "Peripheral nerve block", "procedure_group": "Headache / cranial nerve blocks", "condition": "Peripheral neuropathic pain / post-herpetic neuralgia; Headache / cranial neuralgia; Trigeminal neuralgia / facial neuropathic pain"}}, {"form_id": "trigeminal_branch_block_us", "form_type": "Procedure", "title": "Peripheral trigeminal branch block - ultrasound-guided or landmark-guided", "family": "Headache / cranial nerve blocks", "category": "Headache / cranial nerve blocks", "condition_tags": "Trigeminal branch neuralgia; Facial neuropathic pain", "conditions": ["Trigeminal branch neuralgia", "Facial neuropathic pain"], "template_sheet": "trigeminal_branch_block_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine or seated", "guidance": "Ultrasound-guided or landmark-guided according to branch and anatomy", "guidance_phrase": "Ultrasound guidance and/or landmark guidance was used according to the selected target, depth, and safety considerations. Relevant anatomy and needle path were documented as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Branch-specific superficial perineural approach", "target": "Selected trigeminal branch target region", "needle": "Small-gauge needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid as selected; verify products/DIN", "dose_volume": "Small-volume superficial nerve block injectate", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify products/DIN", "next_procedure_dose": "Small-volume superficial nerve block injectate", "next_procedure_technique": "Ultrasound-guided or landmark-guided according to branch and anatomy; Branch-specific superficial perineural approach; Selected trigeminal branch target region; Small-gauge needle selected by proceduralist", "next_procedure_patient_position": "Supine or seated", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Peripheral trigeminal branch block - ultrasound-guided or landmark-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Cervical spine / head", "guidance_options": ["Ultrasound-guided", "Landmark-guided"], "intervention_type": "Peripheral nerve block", "procedure_group": "Headache / cranial nerve blocks", "condition": "Peripheral neuropathic pain / post-herpetic neuralgia; Headache / cranial neuralgia; Trigeminal neuralgia / facial neuropathic pain"}}, {"form_id": "thoracic_paravertebral_block_us", "form_type": "Procedure", "title": "Thoracic paravertebral block - ultrasound-guided", "family": "Regional anesthesia / fascial plane blocks", "category": "Regional anesthesia / fascial plane blocks", "condition_tags": "Thoracic pain; Intercostal neuralgia; Post-thoracotomy pain", "conditions": ["Thoracic pain", "Intercostal neuralgia", "Post-thoracotomy pain"], "template_sheet": "thoracic_paravertebral_block_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Sitting, lateral, or prone", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane ultrasound-guided approach according to anatomy", "target": "Thoracic paravertebral region at documented level(s)", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without adjunct as selected; verify products/DIN", "dose_volume": "Volume/concentration selected within safety limits", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Local anesthetic with/without adjunct as selected; verify products/DIN", "next_procedure_dose": "Volume/concentration selected within safety limits", "next_procedure_technique": "Ultrasound-guided; In-plane ultrasound-guided approach according to anatomy; Thoracic paravertebral region at documented level(s); Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Sitting, lateral, or prone", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Thoracic paravertebral block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Thoracic spine / chest wall", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regional block", "procedure_group": "Regional anesthesia / fascial plane blocks", "condition": "Thoracic facet / rib / chest wall pain; Intercostal neuralgia / post-thoracotomy pain; Chronic post-surgical pain; Post-mastectomy / post-thoracotomy chest wall pain"}}, {"form_id": "serratus_anterior_plane_block_us", "form_type": "Procedure", "title": "Serratus anterior plane block - ultrasound-guided", "family": "Regional anesthesia / fascial plane blocks", "category": "Regional anesthesia / fascial plane blocks", "condition_tags": "Lateral chest wall pain; Post-thoracotomy pain", "conditions": ["Lateral chest wall pain", "Post-thoracotomy pain"], "template_sheet": "serratus_anterior_plane_block_u", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine, lateral, or seated", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane lateral thoracic wall approach", "target": "Serratus anterior fascial plane at selected rib level", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without adjunct as selected; verify products/DIN", "dose_volume": "Volume/concentration selected within safety limits", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Local anesthetic with/without adjunct as selected; verify products/DIN", "next_procedure_dose": "Volume/concentration selected within safety limits", "next_procedure_technique": "Ultrasound-guided; In-plane lateral thoracic wall approach; Serratus anterior fascial plane at selected rib level; Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Supine, lateral, or seated", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Serratus anterior plane block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Thoracic spine / chest wall", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regional block", "procedure_group": "Regional anesthesia / fascial plane blocks", "condition": "Thoracic facet / rib / chest wall pain; Intercostal neuralgia / post-thoracotomy pain; Chronic post-surgical pain; Post-mastectomy / post-thoracotomy chest wall pain"}}, {"form_id": "pecs_block_us", "form_type": "Procedure", "title": "PECS I / PECS II block - ultrasound-guided", "family": "Regional anesthesia / fascial plane blocks", "category": "Regional anesthesia / fascial plane blocks", "condition_tags": "Anterior chest wall pain; Post-breast surgery pain", "conditions": ["Anterior chest wall pain", "Post-breast surgery pain"], "template_sheet": "pecs_block_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane anterior chest wall approach", "target": "Pectoral fascial plane(s) selected by physician", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without adjunct as selected; verify products/DIN", "dose_volume": "Volume/concentration selected within safety limits", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Local anesthetic with/without adjunct as selected; verify products/DIN", "next_procedure_dose": "Volume/concentration selected within safety limits", "next_procedure_technique": "Ultrasound-guided; In-plane anterior chest wall approach; Pectoral fascial plane(s) selected by physician; Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Supine", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: PECS I / PECS II block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Thoracic spine / chest wall", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regional block", "procedure_group": "Regional anesthesia / fascial plane blocks", "condition": "Intercostal neuralgia / post-thoracotomy pain; Chronic post-surgical pain; Post-mastectomy / post-thoracotomy chest wall pain"}}, {"form_id": "rhomboid_intercostal_plane_block_us", "form_type": "Procedure", "title": "Rhomboid intercostal / subserratus plane block - ultrasound-guided", "family": "Regional anesthesia / fascial plane blocks", "category": "Regional anesthesia / fascial plane blocks", "condition_tags": "Posterior thoracic pain; Scapulothoracic pain", "conditions": ["Posterior thoracic pain", "Scapulothoracic pain"], "template_sheet": "rhomboid_intercostal_plane_bloc", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Sitting, prone, or lateral", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane posterior thoracic wall approach", "target": "Rhomboid intercostal and/or subserratus fascial plane", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without adjunct as selected; verify products/DIN", "dose_volume": "Volume/concentration selected within safety limits", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Local anesthetic with/without adjunct as selected; verify products/DIN", "next_procedure_dose": "Volume/concentration selected within safety limits", "next_procedure_technique": "Ultrasound-guided; In-plane posterior thoracic wall approach; Rhomboid intercostal and/or subserratus fascial plane; Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Sitting, prone, or lateral", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Rhomboid intercostal / subserratus plane block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Thoracic spine / chest wall", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regional block", "procedure_group": "Regional anesthesia / fascial plane blocks", "condition": "Thoracic facet / rib / chest wall pain; Intercostal neuralgia / post-thoracotomy pain; Chronic post-surgical pain; Post-mastectomy / post-thoracotomy chest wall pain"}}, {"form_id": "ganglion_impar_us", "form_type": "Procedure", "title": "Ganglion impar block - ultrasound-guided or landmark-assisted", "family": "Pelvic / sympathetic blocks", "category": "Pelvic / sympathetic blocks", "condition_tags": "Coccydynia; Perineal pain; Pelvic pain", "conditions": ["Coccydynia", "Perineal pain", "Pelvic pain"], "template_sheet": "ganglion_impar_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Prone or lateral", "guidance": "Ultrasound-guided or landmark-assisted according to anatomy; fluoroscopy option remains separate", "guidance_phrase": "Ultrasound guidance and/or landmark guidance was used according to the selected target, depth, and safety considerations. Relevant anatomy and needle path were documented as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Trans-sacrococcygeal or intercoccygeal approach according to anatomy", "target": "Ganglion impar / sacrococcygeal target region", "needle": "Spinal needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid as selected; verify products/DIN", "dose_volume": "Small-volume injectate selected by physician", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify products/DIN", "next_procedure_dose": "Small-volume injectate selected by physician", "next_procedure_technique": "Ultrasound-guided or landmark-assisted according to anatomy; fluoroscopy option remains separate; Trans-sacrococcygeal or intercoccygeal approach according to anatomy; Ganglion impar / sacrococcygeal target region; Spinal needle selected by proceduralist", "next_procedure_patient_position": "Prone or lateral", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Ganglion impar block - ultrasound-guided or landmark-assisted\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / sacroiliac / hip", "guidance_options": ["Ultrasound-guided", "Fluoroscopy-guided", "Landmark-guided"], "intervention_type": "Sympathetic block", "procedure_group": "Pelvic / sympathetic blocks", "condition": "Coccydynia; Pudendal neuralgia / pelvic pain; Chronic pelvic / visceral pelvic pain"}}, {"form_id": "superior_hypogastric_plexus_block_us", "form_type": "Procedure", "title": "Superior hypogastric plexus block - ultrasound-guided or image-guided", "family": "Pelvic / sympathetic blocks", "category": "Pelvic / sympathetic blocks", "condition_tags": "Chronic pelvic pain; Visceral pelvic pain", "conditions": ["Chronic pelvic pain", "Visceral pelvic pain"], "template_sheet": "superior_hypogastric_plexus_blo", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine, prone, or oblique according to approach", "guidance": "Ultrasound-guided or other image-guided technique according to anatomy and protocol", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Anterior or posterior image-guided approach according to protocol", "target": "Superior hypogastric plexus target region", "needle": "Needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid as selected; verify products/DIN", "dose_volume": "Volume/concentration selected by physician", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify products/DIN", "next_procedure_dose": "Volume/concentration selected by physician", "next_procedure_technique": "Ultrasound-guided or other image-guided technique according to anatomy and protocol; Anterior or posterior image-guided approach according to protocol; Superior hypogastric plexus target region; Needle selected by proceduralist", "next_procedure_patient_position": "Supine, prone, or oblique according to approach", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Superior hypogastric plexus block - ultrasound-guided or image-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / sacroiliac / hip", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Sympathetic block", "procedure_group": "Pelvic / sympathetic blocks", "condition": "Pudendal neuralgia / pelvic pain; Chronic post-surgical pain; Chronic pelvic / visceral pelvic pain"}}, {"form_id": "lumbar_sympathetic_block_us", "form_type": "Procedure", "title": "Lumbar sympathetic block - ultrasound-guided or image-guided", "family": "Sympathetic blocks", "category": "Sympathetic blocks", "condition_tags": "Lower limb CRPS; Sympathetically maintained lower limb pain", "conditions": ["Lower limb CRPS", "Sympathetically maintained lower limb pain"], "template_sheet": "lumbar_sympathetic_block_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Prone or lateral according to approach", "guidance": "Ultrasound-guided where feasible or other image-guided technique according to anatomy/protocol", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Posterolateral target-specific approach with vascular/visceral avoidance", "target": "Lumbar sympathetic chain target region", "needle": "Spinal or block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without adjunct as selected; verify dose and contraindications", "dose_volume": "Volume/concentration selected by physician and documented", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Local anesthetic with/without adjunct as selected; verify dose and contraindications", "next_procedure_dose": "Volume/concentration selected by physician and documented", "next_procedure_technique": "Ultrasound-guided where feasible or other image-guided technique according to anatomy/protocol; Posterolateral target-specific approach with vascular/visceral avoidance; Lumbar sympathetic chain target region; Spinal or block needle selected by proceduralist", "next_procedure_patient_position": "Prone or lateral according to approach", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Lumbar sympathetic block - ultrasound-guided or image-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Lumbar spine", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Sympathetic block", "procedure_group": "Sympathetic blocks", "condition": "Complex regional pain syndrome; Peripheral neuropathic pain / post-herpetic neuralgia; Sympathetically maintained pain"}}, {"form_id": "transversus_abdominis_plane_block_us", "form_type": "Procedure", "title": "Transversus abdominis plane block - ultrasound-guided", "family": "Regional anesthesia / fascial plane blocks", "category": "Regional anesthesia / fascial plane blocks", "condition_tags": "Abdominal wall pain; Post-surgical abdominal wall pain; Ilioinguinal/iliohypogastric distribution pain", "conditions": ["Abdominal wall pain", "Post-surgical abdominal wall pain", "Ilioinguinal/iliohypogastric distribution pain"], "template_sheet": "transversus_abdominis_plane_blo", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane lateral or subcostal TAP approach according to pain distribution", "target": "Plane between internal oblique and transversus abdominis", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid or adjunct as selected; verify dose", "dose_volume": "Plane block volume/concentration selected within safety limits", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid or adjunct as selected; verify dose", "next_procedure_dose": "Plane block volume/concentration selected within safety limits", "next_procedure_technique": "Ultrasound-guided; In-plane lateral or subcostal TAP approach according to pain distribution; Plane between internal oblique and transversus abdominis; Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Supine", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Transversus abdominis plane block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Abdomen / pelvis", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regional block", "procedure_group": "Regional anesthesia / fascial plane blocks", "condition": "Ilioinguinal/iliohypogastric/genitofemoral neuralgia; Chronic post-surgical pain; Abdominal wall pain / ACNES / post-surgical abdominal wall pain"}}, {"form_id": "obturator_nerve_block_us", "form_type": "Procedure", "title": "Obturator nerve block - ultrasound-guided", "family": "Pelvic / lower limb nerve blocks", "category": "Pelvic / lower limb nerve blocks", "condition_tags": "Hip/groin pain; Obturator neuralgia", "conditions": ["Hip/groin pain", "Obturator neuralgia"], "template_sheet": "obturator_nerve_block_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine with hip externally rotated as tolerated", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Ultrasound-guided adductor compartment approach", "target": "Anterior/posterior obturator nerve branches or obturator nerve target region", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid as selected; verify products/DIN", "dose_volume": "Low-volume perineural injectate by branch/target", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify products/DIN", "next_procedure_dose": "Low-volume perineural injectate by branch/target", "next_procedure_technique": "Ultrasound-guided; Ultrasound-guided adductor compartment approach; Anterior/posterior obturator nerve branches or obturator nerve target region; Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Supine with hip externally rotated as tolerated", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Obturator nerve block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / sacroiliac / hip", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Peripheral nerve block", "procedure_group": "Pelvic / lower limb nerve blocks", "condition": "Hip osteoarthritis / chronic groin pain; Peripheral neuropathic pain / post-herpetic neuralgia; Obturator neuralgia / medial groin pain"}}, {"form_id": "femoral_nerve_block_us", "form_type": "Procedure", "title": "Femoral nerve block - ultrasound-guided", "family": "Pelvic / lower limb nerve blocks", "category": "Pelvic / lower limb nerve blocks", "condition_tags": "Femoral neuralgia; Anterior thigh pain; Hip/knee pain", "conditions": ["Femoral neuralgia", "Anterior thigh pain", "Hip/knee pain"], "template_sheet": "femoral_nerve_block_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane inguinal approach avoiding vascular structures", "target": "Femoral nerve target region", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without steroid as selected; verify products/DIN", "dose_volume": "Volume/concentration selected within safety limits", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic with/without steroid as selected; verify products/DIN", "next_procedure_dose": "Volume/concentration selected within safety limits", "next_procedure_technique": "Ultrasound-guided; In-plane inguinal approach avoiding vascular structures; Femoral nerve target region; Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Supine", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Femoral nerve block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / sacroiliac / hip", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Peripheral nerve block", "procedure_group": "Pelvic / lower limb nerve blocks", "condition": "Knee osteoarthritis / chronic knee pain; Hip osteoarthritis / chronic groin pain; Peripheral neuropathic pain / post-herpetic neuralgia; Femoral neuralgia / anterior thigh neuropathic pain"}}, {"form_id": "pengi_block_us", "form_type": "Procedure", "title": "Pericapsular nerve group (PENG) block - ultrasound-guided", "family": "Hip articular nerve blocks", "category": "Hip articular nerve blocks", "condition_tags": "Hip osteoarthritis; Chronic anterior hip pain", "conditions": ["Hip osteoarthritis", "Chronic anterior hip pain"], "template_sheet": "pengi_block_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "In-plane anterior approach", "target": "Plane between psoas tendon and pubic ramus / articular branch target region", "needle": "Echogenic block needle selected by proceduralist", "injectate_product": "Local anesthetic with/without adjunct as selected; verify products/DIN", "dose_volume": "Volume/concentration selected within safety limits", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Local anesthetic with/without adjunct as selected; verify products/DIN", "next_procedure_dose": "Volume/concentration selected within safety limits", "next_procedure_technique": "Ultrasound-guided; In-plane anterior approach; Plane between psoas tendon and pubic ramus / articular branch target region; Echogenic block needle selected by proceduralist", "next_procedure_patient_position": "Supine", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Pericapsular nerve group (PENG) block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / sacroiliac / hip", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Regional block", "procedure_group": "Hip articular nerve blocks", "condition": "Hip osteoarthritis / chronic groin pain"}}, {"form_id": "shoulder_articular_branch_block_us", "form_type": "Procedure", "title": "Shoulder articular branch block - ultrasound-guided", "family": "Shoulder nerve procedures", "category": "Shoulder nerve procedures", "condition_tags": "Chronic shoulder pain; Glenohumeral osteoarthritis", "conditions": ["Chronic shoulder pain", "Glenohumeral osteoarthritis"], "template_sheet": "shoulder_articular_branch_block", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Seated, lateral, or prone according to target", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Target-specific ultrasound-guided approach", "target": "Selected suprascapular, axillary, lateral pectoral, or other shoulder articular branch target(s)", "needle": "Echogenic needle selected by proceduralist", "injectate_product": "Local anesthetic diagnostic block injectate with/without steroid as selected", "dose_volume": "Low-volume injectate by target", "diluent_anesthetic": "Local anesthetic and/or preservative-free saline as selected.", "next_procedure_medication_choice": "Local anesthetic diagnostic block injectate with/without steroid as selected", "next_procedure_dose": "Low-volume injectate by target", "next_procedure_technique": "Ultrasound-guided; Target-specific ultrasound-guided approach; Selected suprascapular, axillary, lateral pectoral, or other shoulder articular branch target(s); Echogenic needle selected by proceduralist", "next_procedure_patient_position": "Seated, lateral, or prone according to target", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Shoulder articular branch block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Shoulder", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Peripheral nerve block", "procedure_group": "Shoulder nerve procedures", "condition": "Shoulder osteoarthritis / adhesive capsulitis; Rotator cuff tendinopathy / subacromial pain"}}, {"form_id": "shoulder_articular_branch_rfa", "form_type": "Procedure", "title": "Shoulder articular branch radiofrequency ablation - image-guided", "family": "Shoulder nerve procedures", "category": "Shoulder nerve procedures", "condition_tags": "Chronic shoulder pain; Shoulder osteoarthritis", "conditions": ["Chronic shoulder pain", "Shoulder osteoarthritis"], "template_sheet": "shoulder_articular_branch_rfa", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Positioned according to selected target(s)", "guidance": "Ultrasound-guided or fluoroscopy-guided according to target and protocol", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Target-specific image-guided RF cannula placement", "target": "Selected shoulder articular sensory branch targets", "needle": "RF cannula/electrode selected by proceduralist", "injectate_product": "Radiofrequency treatment; local anesthetic/post-lesion injectate as selected", "dose_volume": "RF mode, temperature/duration or PRF settings, lesion count, and injectate volume documented", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Radiofrequency treatment; local anesthetic/post-lesion injectate as selected", "next_procedure_dose": "RF mode, temperature/duration or PRF settings, lesion count, and injectate volume documented", "next_procedure_technique": "Ultrasound-guided or fluoroscopy-guided according to target and protocol; Target-specific image-guided RF cannula placement; Selected shoulder articular sensory branch targets; RF cannula/electrode selected by proceduralist", "next_procedure_patient_position": "Positioned according to selected target(s)", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating nerve ablation/RFA, usual interval is about every year or longer unless physician documents a different rationale; reassess indication, diagnostic response, neurologic status, and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Shoulder articular branch radiofrequency ablation - image-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Shoulder", "guidance_options": ["Ultrasound-guided", "Fluoroscopy-guided"], "intervention_type": "Ablation / PRF", "procedure_group": "Shoulder nerve procedures", "condition": "Shoulder osteoarthritis / adhesive capsulitis; Rotator cuff tendinopathy / subacromial pain"}}, {"form_id": "suprascapular_nerve_rfa_us", "form_type": "Procedure", "title": "Suprascapular nerve pulsed radiofrequency / ablation - ultrasound-guided", "family": "Shoulder nerve procedures", "category": "Shoulder nerve procedures", "condition_tags": "Chronic shoulder pain; Suprascapular neuralgia", "conditions": ["Chronic shoulder pain", "Suprascapular neuralgia"], "template_sheet": "suprascapular_nerve_rfa_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Seated, prone, or lateral", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Ultrasound-guided RF cannula placement near target nerve", "target": "Suprascapular nerve target region", "needle": "RF cannula/electrode selected by proceduralist", "injectate_product": "Pulsed RF or ablation treatment; local anesthetic as selected", "dose_volume": "PRF/RF settings, duration, sensory/motor testing, and injectate volume documented", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Pulsed RF or ablation treatment; local anesthetic as selected", "next_procedure_dose": "PRF/RF settings, duration, sensory/motor testing, and injectate volume documented", "next_procedure_technique": "Ultrasound-guided; Ultrasound-guided RF cannula placement near target nerve; Suprascapular nerve target region; RF cannula/electrode selected by proceduralist", "next_procedure_patient_position": "Seated, prone, or lateral", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating nerve ablation/RFA, usual interval is about every year or longer unless physician documents a different rationale; reassess indication, diagnostic response, neurologic status, and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Suprascapular nerve pulsed radiofrequency / ablation - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Shoulder", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Ablation / PRF", "procedure_group": "Shoulder nerve procedures", "condition": "Shoulder osteoarthritis / adhesive capsulitis; Rotator cuff tendinopathy / subacromial pain"}}, {"form_id": "genicular_nerve_block_us", "form_type": "Procedure", "title": "Genicular nerve diagnostic block - ultrasound-guided", "family": "Knee genicular procedures", "category": "Knee genicular procedures", "condition_tags": "Knee osteoarthritis; Chronic knee pain", "conditions": ["Knee osteoarthritis", "Chronic knee pain"], "template_sheet": "genicular_nerve_block_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine with knee supported", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Target-specific in-plane or out-of-plane approach", "target": "Superior medial, superior lateral, inferior medial and/or additional genicular nerve targets as selected", "needle": "Echogenic needle selected by proceduralist", "injectate_product": "Local anesthetic diagnostic block injectate", "dose_volume": "Low-volume local anesthetic per target", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Local anesthetic diagnostic block injectate", "next_procedure_dose": "Low-volume local anesthetic per target", "next_procedure_technique": "Ultrasound-guided; Target-specific in-plane or out-of-plane approach; Superior medial, superior lateral, inferior medial and/or additional genicular nerve targets as selected; Echogenic needle selected by proceduralist", "next_procedure_patient_position": "Supine with knee supported", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Genicular nerve diagnostic block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Knee", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Peripheral nerve block", "procedure_group": "Knee genicular procedures", "condition": "Knee osteoarthritis / chronic knee pain"}}, {"form_id": "genicular_prf_us", "form_type": "Procedure", "title": "Genicular nerve pulsed radiofrequency - ultrasound-guided", "family": "Knee genicular procedures", "category": "Knee genicular procedures", "condition_tags": "Knee osteoarthritis; Chronic knee pain", "conditions": ["Knee osteoarthritis", "Chronic knee pain"], "template_sheet": "genicular_prf_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine with knee supported", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Target-specific ultrasound-guided RF cannula placement", "target": "Selected genicular nerve targets", "needle": "RF cannula/electrode selected by proceduralist", "injectate_product": "Pulsed RF treatment; local anesthetic as selected", "dose_volume": "PRF settings, duration, sensory/motor testing, and injectate volume documented", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Pulsed RF treatment; local anesthetic as selected", "next_procedure_dose": "PRF settings, duration, sensory/motor testing, and injectate volume documented", "next_procedure_technique": "Ultrasound-guided; Target-specific ultrasound-guided RF cannula placement; Selected genicular nerve targets; RF cannula/electrode selected by proceduralist", "next_procedure_patient_position": "Supine with knee supported", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating nerve ablation/RFA, usual interval is about every year or longer unless physician documents a different rationale; reassess indication, diagnostic response, neurologic status, and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Genicular nerve pulsed radiofrequency - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Knee", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Ablation / PRF", "procedure_group": "Knee genicular procedures", "condition": "Knee osteoarthritis / chronic knee pain"}}, {"form_id": "hip_articular_branch_block_us", "form_type": "Procedure", "title": "Hip articular branch diagnostic block - ultrasound-guided", "family": "Hip articular nerve blocks", "category": "Hip articular nerve blocks", "condition_tags": "Hip osteoarthritis; Chronic hip/groin pain", "conditions": ["Hip osteoarthritis", "Chronic hip/groin pain"], "template_sheet": "hip_articular_branch_block_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Target-specific ultrasound-guided approach", "target": "Femoral and/or obturator articular branch target region(s)", "needle": "Echogenic needle selected by proceduralist", "injectate_product": "Local anesthetic diagnostic block injectate", "dose_volume": "Low-volume injectate by target", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Local anesthetic diagnostic block injectate", "next_procedure_dose": "Low-volume injectate by target", "next_procedure_technique": "Ultrasound-guided; Target-specific ultrasound-guided approach; Femoral and/or obturator articular branch target region(s); Echogenic needle selected by proceduralist", "next_procedure_patient_position": "Supine", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Hip articular branch diagnostic block - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / sacroiliac / hip", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Peripheral nerve block", "procedure_group": "Hip articular nerve blocks", "condition": "Hip osteoarthritis / chronic groin pain"}}, {"form_id": "hip_articular_branch_rfa", "form_type": "Procedure", "title": "Hip articular branch radiofrequency ablation - image-guided", "family": "Hip articular nerve blocks", "category": "Hip articular nerve blocks", "condition_tags": "Hip osteoarthritis; Chronic hip/groin pain", "conditions": ["Hip osteoarthritis", "Chronic hip/groin pain"], "template_sheet": "hip_articular_branch_rfa", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Supine", "guidance": "Ultrasound-guided or fluoroscopy-guided according to target and protocol", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Target-specific image-guided RF cannula placement", "target": "Femoral and/or obturator articular sensory branch targets", "needle": "RF cannula/electrode selected by proceduralist", "injectate_product": "Radiofrequency treatment; local anesthetic/post-lesion injectate as selected", "dose_volume": "RF settings, lesion count, and injectate volume documented", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Radiofrequency treatment; local anesthetic/post-lesion injectate as selected", "next_procedure_dose": "RF settings, lesion count, and injectate volume documented", "next_procedure_technique": "Ultrasound-guided or fluoroscopy-guided according to target and protocol; Target-specific image-guided RF cannula placement; Femoral and/or obturator articular sensory branch targets; RF cannula/electrode selected by proceduralist", "next_procedure_patient_position": "Supine", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating nerve ablation/RFA, usual interval is about every year or longer unless physician documents a different rationale; reassess indication, diagnostic response, neurologic status, and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Hip articular branch radiofrequency ablation - image-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Pelvis / sacroiliac / hip", "guidance_options": ["Ultrasound-guided", "Fluoroscopy-guided"], "intervention_type": "Ablation / PRF", "procedure_group": "Hip articular nerve blocks", "condition": "Hip osteoarthritis / chronic groin pain"}}, {"form_id": "peripheral_nerve_prf_us", "form_type": "Procedure", "title": "Peripheral nerve pulsed radiofrequency - ultrasound-guided", "family": "Peripheral nerve stimulation / PRF", "category": "Peripheral nerve stimulation / PRF", "condition_tags": "Peripheral neuropathic pain; Post-surgical neuralgia", "conditions": ["Peripheral neuropathic pain", "Post-surgical neuralgia"], "template_sheet": "peripheral_nerve_prf_us", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Positioned according to target nerve", "guidance": "Ultrasound-guided", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Target-specific ultrasound-guided RF cannula placement", "target": "Selected peripheral nerve target documented by physician", "needle": "RF cannula/electrode selected by proceduralist", "injectate_product": "Pulsed RF treatment; local anesthetic as selected", "dose_volume": "PRF settings, duration, sensory/motor testing, and injectate volume documented", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Pulsed RF treatment; local anesthetic as selected", "next_procedure_dose": "PRF settings, duration, sensory/motor testing, and injectate volume documented", "next_procedure_technique": "Ultrasound-guided; Target-specific ultrasound-guided RF cannula placement; Selected peripheral nerve target documented by physician; RF cannula/electrode selected by proceduralist", "next_procedure_patient_position": "Positioned according to target nerve", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating nerve ablation/RFA, usual interval is about every year or longer unless physician documents a different rationale; reassess indication, diagnostic response, neurologic status, and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Peripheral nerve pulsed radiofrequency - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "General / multisite pain", "guidance_options": ["Ultrasound-guided"], "intervention_type": "Ablation / PRF", "procedure_group": "Peripheral nerve stimulation / PRF", "condition": "Ilioinguinal/iliohypogastric/genitofemoral neuralgia; Superior cluneal neuralgia; Peripheral neuropathic pain / post-herpetic neuralgia; Chronic post-surgical pain; Meralgia paresthetica / lateral femoral cutaneous neuralgia; Tarsal tunnel syndrome / tibial neuralgia; Common peroneal neuralgia / lateral leg neuropathic pain; Saphenous neuralgia / medial knee neuropathic pain; Obturator neuralgia / medial groin pain; Femoral neuralgia / anterior thigh neuropathic pain; Phantom limb pain / stump pain; Post-herniorrhaphy groin pain; Abdominal wall pain / ACNES / post-surgical abdominal wall pain; Sympathetically maintained pain"}}, {"form_id": "peripheral_nerve_stimulation_trial_us", "form_type": "Procedure", "title": "Peripheral nerve stimulation trial lead placement - ultrasound-guided", "family": "Peripheral nerve stimulation / PRF", "category": "Peripheral nerve stimulation / PRF", "condition_tags": "Peripheral neuropathic pain; Chronic post-surgical pain; Chronic regional pain", "conditions": ["Peripheral neuropathic pain", "Chronic post-surgical pain", "Chronic regional pain"], "template_sheet": "peripheral_nerve_stimulation_tr", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Positioned according to target nerve and device workflow", "guidance": "Ultrasound-guided and/or fluoroscopy-assisted according to target and device protocol", "guidance_phrase": "Real-time ultrasound guidance was used. Needle tip location, target region, injectate spread, and relevant surrounding structures were visualized as feasible.", "transducer_or_equipment": "Ultrasound transducer selected according to target depth and body habitus", "approach": "Device-specific percutaneous lead placement approach", "target": "Selected peripheral nerve stimulation target documented by physician", "needle": "PNS introducer/lead system selected and verified", "injectate_product": "Peripheral nerve stimulation lead/device; local anesthetic as selected", "dose_volume": "Lead model, stimulation program, local anesthetic volume, and device identifiers documented", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Peripheral nerve stimulation lead/device; local anesthetic as selected", "next_procedure_dose": "Lead model, stimulation program, local anesthetic volume, and device identifiers documented", "next_procedure_technique": "Ultrasound-guided and/or fluoroscopy-assisted according to target and device protocol; Device-specific percutaneous lead placement approach; Selected peripheral nerve stimulation target documented by physician; PNS introducer/lead system selected and verified", "next_procedure_patient_position": "Positioned according to target nerve and device workflow", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Peripheral nerve stimulation trial lead placement - ultrasound-guided\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "General / multisite pain", "guidance_options": ["Ultrasound-guided", "Fluoroscopy-guided"], "intervention_type": "Stimulation / neuromodulation", "procedure_group": "Peripheral nerve stimulation / PRF", "condition": "Knee osteoarthritis / chronic knee pain; Shoulder osteoarthritis / adhesive capsulitis; Superior cluneal neuralgia; Peripheral neuropathic pain / post-herpetic neuralgia; Chronic post-surgical pain; Post-mastectomy / post-thoracotomy chest wall pain; Meralgia paresthetica / lateral femoral cutaneous neuralgia; Tarsal tunnel syndrome / tibial neuralgia; Common peroneal neuralgia / lateral leg neuropathic pain; Saphenous neuralgia / medial knee neuropathic pain; Phantom limb pain / stump pain; Post-herniorrhaphy groin pain; Abdominal wall pain / ACNES / post-surgical abdominal wall pain"}}, {"form_id": "sprint_or_pns_followup_programming", "form_type": "Procedure", "title": "Peripheral nerve stimulator programming / follow-up", "family": "Peripheral nerve stimulation / PRF", "category": "Peripheral nerve stimulation / PRF", "condition_tags": "Peripheral nerve stimulation follow-up; Chronic regional pain", "conditions": ["Peripheral nerve stimulation follow-up", "Chronic regional pain"], "template_sheet": "sprint_or_pns_followup_programm", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Comfortable position for programming and assessment", "guidance": "N/A - device programming/follow-up", "guidance_phrase": "Guidance and target confirmation were performed according to the selected technique and documented findings.", "transducer_or_equipment": "Procedure-specific equipment", "approach": "Programming, impedance/status check, patient feedback, and setting adjustment", "target": "Active PNS target/lead location documented from prior procedure", "needle": "N/A - implanted or percutaneous stimulator follow-up", "injectate_product": "Peripheral nerve stimulator programming; no injectate unless separately documented", "dose_volume": "Program settings, amplitude/frequency/pulse width if available, and patient response documented", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Peripheral nerve stimulator programming; no injectate unless separately documented", "next_procedure_dose": "Program settings, amplitude/frequency/pulse width if available, and patient response documented", "next_procedure_technique": "N/A - device programming/follow-up; Programming, impedance/status check, patient feedback, and setting adjustment; Active PNS target/lead location documented from prior procedure; N/A - implanted or percutaneous stimulator follow-up", "next_procedure_patient_position": "Comfortable position for programming and assessment", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Peripheral nerve stimulator programming / follow-up\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "General / multisite pain", "guidance_options": ["N/A"], "intervention_type": "Stimulation / neuromodulation", "procedure_group": "Peripheral nerve stimulation / PRF", "condition": "Knee osteoarthritis / chronic knee pain; Shoulder osteoarthritis / adhesive capsulitis; Superior cluneal neuralgia; Peripheral neuropathic pain / post-herpetic neuralgia; Chronic post-surgical pain"}}, {"form_id": "scs_trial_followup_template", "form_type": "Procedure", "title": "Spinal cord stimulator trial / follow-up documentation", "family": "Spinal cord stimulation (SCS)", "category": "Spinal cord stimulation (SCS)", "condition_tags": "Failed back surgery syndrome; CRPS; Chronic neuropathic pain", "conditions": ["Failed back surgery syndrome", "CRPS", "Chronic neuropathic pain"], "template_sheet": "scs_trial_followup_template", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Prone for lead placement; comfortable position for programming/follow-up", "guidance": "Fluoroscopy-guided for lead placement; N/A for programming/follow-up", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions and contrast confirmation when applicable and not contraindicated.", "transducer_or_equipment": "Fluoroscopy unit", "approach": "SCS trial/lead/programming workflow according to device protocol", "target": "Epidural lead target level or active stimulation coverage region", "needle": "SCS needle/lead system or programmer as applicable", "injectate_product": "Spinal cord stimulation device workflow; local anesthetic/sedation as separately documented", "dose_volume": "Lead level, program settings, coverage, paresthesia-free program if used, and response documented", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Spinal cord stimulation device workflow; local anesthetic/sedation as separately documented", "next_procedure_dose": "Lead level, program settings, coverage, paresthesia-free program if used, and response documented", "next_procedure_technique": "Fluoroscopy-guided for lead placement; N/A for programming/follow-up; SCS trial/lead/programming workflow according to device protocol; Epidural lead target level or active stimulation coverage region; SCS needle/lead system or programmer as applicable", "next_procedure_patient_position": "Prone for lead placement; comfortable position for programming/follow-up", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Spinal cord stimulator trial / follow-up documentation\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "General / multisite pain", "guidance_options": ["Fluoroscopy-guided", "N/A"], "intervention_type": "Stimulation / neuromodulation", "procedure_group": "Spinal cord stimulation (SCS)", "condition": "Lumbar radicular pain / sciatica; Complex regional pain syndrome; Peripheral neuropathic pain / post-herpetic neuralgia; Chronic post-surgical pain; Failed back surgery syndrome / persistent spinal pain syndrome"}}, {"form_id": "dorsal_root_ganglion_stimulation_template", "form_type": "Procedure", "title": "Dorsal root ganglion stimulation trial / follow-up documentation", "family": "Dorsal root ganglion stimulation (DRG-S)", "category": "Dorsal root ganglion stimulation (DRG-S)", "condition_tags": "CRPS; Focal neuropathic pain", "conditions": ["CRPS", "Focal neuropathic pain"], "template_sheet": "dorsal_root_ganglion_stimulatio", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Prone for lead placement; comfortable position for programming/follow-up", "guidance": "Fluoroscopy-guided for lead placement; N/A for programming/follow-up", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions and contrast confirmation when applicable and not contraindicated.", "transducer_or_equipment": "Fluoroscopy unit", "approach": "DRG stimulation trial/lead/programming workflow according to device protocol", "target": "Selected DRG target level(s) or active stimulation coverage region", "needle": "DRG stimulation lead system or programmer as applicable", "injectate_product": "DRG stimulation device workflow; local anesthetic/sedation as separately documented", "dose_volume": "Lead level, program settings, coverage, and response documented", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "DRG stimulation device workflow; local anesthetic/sedation as separately documented", "next_procedure_dose": "Lead level, program settings, coverage, and response documented", "next_procedure_technique": "Fluoroscopy-guided for lead placement; N/A for programming/follow-up; DRG stimulation trial/lead/programming workflow according to device protocol; Selected DRG target level(s) or active stimulation coverage region; DRG stimulation lead system or programmer as applicable", "next_procedure_patient_position": "Prone for lead placement; comfortable position for programming/follow-up", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "Reassess indication, response to the current procedure, contraindications, patient preference, and affordability before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Dorsal root ganglion stimulation trial / follow-up documentation\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "General / multisite pain", "guidance_options": ["Fluoroscopy-guided", "N/A"], "intervention_type": "Stimulation / neuromodulation", "procedure_group": "Dorsal root ganglion stimulation (DRG-S)", "condition": "Complex regional pain syndrome; Peripheral neuropathic pain / post-herpetic neuralgia; Chronic post-surgical pain; Failed back surgery syndrome / persistent spinal pain syndrome"}}, {"form_id": "basivertebral_nerve_ablation_intracept_template", "form_type": "Procedure", "title": "Basivertebral nerve ablation / Intracept procedure documentation", "family": "Basivertebral nerve ablation (Intracept)", "category": "Basivertebral nerve ablation (Intracept)", "condition_tags": "Vertebrogenic low back pain; Modic change-associated low back pain", "conditions": ["Vertebrogenic low back pain", "Modic change-associated low back pain"], "template_sheet": "basivertebral_nerve_ablation_in", "status": "v0.8 generated taxonomy expansion - physician review required", "defaults": {"patient_position": "Prone", "guidance": "Fluoroscopy-guided according to device/procedure protocol", "guidance_phrase": "Fluoroscopic image guidance was used with standard radiation safety precautions and contrast confirmation when applicable and not contraindicated.", "transducer_or_equipment": "Fluoroscopy unit", "approach": "Transpedicular access according to device protocol", "target": "Basivertebral nerve target in selected vertebral body level(s)", "needle": "Basivertebral nerve ablation access cannula/device system", "injectate_product": "Basivertebral nerve ablation device workflow; medications documented separately", "dose_volume": "Device, level(s), ablation settings, duration, and identifiers documented", "diluent_anesthetic": "Medication mix selected by physician and documented.", "next_procedure_medication_choice": "Basivertebral nerve ablation device workflow; medications documented separately", "next_procedure_dose": "Device, level(s), ablation settings, duration, and identifiers documented", "next_procedure_technique": "Fluoroscopy-guided according to device/procedure protocol; Transpedicular access according to device protocol; Basivertebral nerve target in selected vertebral body level(s); Basivertebral nerve ablation access cannula/device system", "next_procedure_patient_position": "Prone", "next_procedure_premedication": "Same as current procedure if used; otherwise none planned unless clinically indicated.", "next_procedure_pre_procedure_comments": "If repeating nerve ablation/RFA, usual interval is about every year or longer unless physician documents a different rationale; reassess indication, diagnostic response, neurologic status, and contraindications before proceeding.", "next_procedure_intra_procedure_comments": "Use the same documented technique unless anatomy, response, or safety considerations require modification.", "next_procedure_post_procedure_comments": "Reassess response, adverse effects, function, and need for further treatment after the next procedure."}, "fields": [{"section": "Safety", "key": "consent_phrase", "label": "Consent discussion", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Editable global consent language; add procedure-specific risks.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "timeout_phrase", "label": "Time-out and safety screen", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "No default should be trusted if actual safety screen differs.", "quick_options": ["Reviewed today and no patient-specific contraindication identified.", "Patient-specific exception documented in the free-text field."]}, {"section": "Safety", "key": "allergy_infection_anticoagulant_screen", "label": "Allergy / infection / anticoagulant / medication safety screen", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only patient-specific safety finding.", "quick_options": ["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'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."], "context_sources": ["red_flags_neuro_screen", "red_flag_exam_findings", "current_medications"]}, {"section": "Indication", "key": "diagnosis", "label": "Diagnosis / indication", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only patient-specific diagnosis.", "context_sources": ["condition_focus", "pain_generator_impression", "history_impression_plan"]}, {"section": "Indication", "key": "clinical_indication", "label": "Clinical indication and failed conservative therapy", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only rationale for this procedure.", "quick_options": ["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."], "context_sources": ["presenting_complaint", "pain_location_distribution", "functional_limitations", "prior_treatments", "imaging_labs_tests", "pain_generator_impression", "procedural_target_assessment"]}, {"section": "Indication", "key": "side", "label": "Laterality / side", "default_layer": "No Default", "input_type": "select", "required": true, "options": "Right;Left;Bilateral;Midline;N/A", "help": "Manual-only wrong-site safety field."}, {"section": "Indication", "key": "baseline_pain_function", "label": "Baseline pain / function before procedure", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only baseline before intervention.", "quick_options": ["Baseline pain score documented; pain limits walking, stairs, transfers, sleep, work, exercise, or self-care as described by patient.", "Baseline function and patient-specific goals reviewed before treatment.", "Pain diary baseline reviewed before procedure.", "Patient identifies the main functional goal as improved activity tolerance and reduced medication reliance.", "Baseline neurologic symptoms and functional limitations reviewed before intervention."]}, {"section": "Setup", "key": "patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Setup", "key": "skin_prep", "label": "Skin preparation", "default_layer": "Global Default", "input_type": "text", "required": true, "options": "", "help": "Global default with allergy override."}, {"section": "Setup", "key": "sterile_setup", "label": "Sterile setup", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global sterile technique text."}, {"section": "Setup", "key": "monitoring", "label": "Monitoring", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Select monitoring appropriate to injection, ablation, or stimulation."}, {"section": "Guidance", "key": "guidance", "label": "Guidance modality", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific imaging or landmark technique."}, {"section": "Guidance", "key": "guidance_phrase", "label": "Guidance documentation phrase", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Edit to match ultrasound, fluoroscopy, or landmark technique actually used."}, {"section": "Guidance", "key": "image_saved", "label": "Images saved / archive location", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only: document if images saved and where.", "quick_options": ["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."], "context_sources": ["imaging_labs_tests", "procedural_target_assessment"]}, {"section": "Technique", "key": "transducer_or_equipment", "label": "Transducer / equipment", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Probe/equipment used for the selected technique."}, {"section": "Technique", "key": "approach", "label": "Needle approach", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique to procedure; edit if changed."}, {"section": "Technique", "key": "target", "label": "Needle target", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Unique target for procedure/product type."}, {"section": "Technique", "key": "needle", "label": "Needle / cannula / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Procedure-specific default; edit if changed."}, {"section": "Technique", "key": "levels_targets", "label": "Levels / target sites treated", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only levels, side, or target sites.", "quick_options": ["Target level(s)/site(s) confirmed with patient, exam, and available imaging before procedure.", "Right-sided target(s) as documented.", "Left-sided target(s) as documented.", "Bilateral target(s) as documented.", "Most symptomatic level/site treated today; additional targets deferred unless clinically indicated.", "Multiple targets treated because symptoms and exam findings were concordant at each site."]}, {"section": "Technique", "key": "needle_visualization", "label": "Needle visualization / path / endpoint confirmation", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual visualization and safety observations.", "quick_options": ["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."], "context_sources": ["procedural_target_assessment", "condition_specific_exam"]}, {"section": "Technique", "key": "aspiration_result", "label": "Aspiration / stimulation / safety check", "default_layer": "No Default", "input_type": "text", "required": true, "options": "Negative;Positive;Not applicable", "help": "Manual-only actual finding.", "quick_options": ["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."]}, {"section": "Technique", "key": "injection_character", "label": "Injection character / spread / resistance / response", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual spread/resistance/response.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "injectate_product", "label": "Medication / product / device", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Verify product, route appropriateness, DIN/device status, concentration, and patient-specific dose."}, {"section": "Injectate/Product", "key": "dose_volume", "label": "Dose / volume / settings", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Visible physician-reviewed dose, volume, or device settings."}, {"section": "Injectate/Product", "key": "diluent_anesthetic", "label": "Medication mix / diluent / local anesthetic", "default_layer": "Per-Form Default", "input_type": "text", "required": false, "options": "", "help": "Medication mix should be selected/edited for the encounter."}, {"section": "Injectate/Product", "key": "total_volume", "label": "Total volume / total treatment delivered", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only actual total volume/treatment.", "quick_options": ["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."]}, {"section": "Injectate/Product", "key": "lot_expiry", "label": "Lot / expiry / device identifiers", "default_layer": "No Default", "input_type": "text", "required": true, "options": "", "help": "Manual-only product/device tracking if required by clinic policy.", "quick_options": ["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."]}, {"section": "Outcome", "key": "immediate_response", "label": "Immediate response / pain score change", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "", "help": "Manual-only actual response.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan"]}, {"section": "Outcome", "key": "complications", "label": "Complications / adverse event", "default_layer": "No Default", "input_type": "textarea", "required": true, "options": "None;Vasovagal;Bleeding;Paresthesia;Other", "help": "Manual-only actual complications.", "quick_options": ["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."]}, {"section": "Disposition", "key": "post_procedure_instructions", "label": "Post-procedure instructions", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit for procedure-specific warnings.", "quick_options": ["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."]}, {"section": "Disposition", "key": "follow_up_plan", "label": "Follow-up plan", "default_layer": "Global Default", "input_type": "textarea", "required": true, "options": "", "help": "Global default; edit according to treatment plan.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_date", "label": "Recommended next procedure date", "default_layer": "No Default", "input_type": "date", "required": true, "options": "", "help": "Manual-only. Enter planned date, approximate date, or document N/A if no repeat is planned."}, {"section": "Recommended next procedure", "key": "next_procedure_medication_choice", "label": "Medication choice", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure medication/product choice; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_dose", "label": "Dose", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure dose/volume/settings; edit for the next procedure."}, {"section": "Recommended next procedure", "key": "next_procedure_technique", "label": "Technique", "default_layer": "Per-Form Default", "input_type": "textarea", "required": true, "options": "", "help": "Defaults from current guidance, approach, target, and needle details."}, {"section": "Recommended next procedure", "key": "next_procedure_patient_position", "label": "Patient position", "default_layer": "Per-Form Default", "input_type": "text", "required": true, "options": "", "help": "Defaults from the current procedure position; edit if the next procedure should differ."}, {"section": "Recommended next procedure", "key": "next_procedure_premedication", "label": "Premedication", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Defaults to the current/typical plan; edit for anxiolysis, allergy prophylaxis, antibiotics, or none."}, {"section": "Recommended next procedure", "key": "next_procedure_pre_procedure_comments", "label": "Pre-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable planning comments before the next procedure.", "quick_options": ["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."], "context_sources": ["history_impression_plan", "exam_plan", "patient_preferences_affordability"]}, {"section": "Recommended next procedure", "key": "next_procedure_intra_procedure_comments", "label": "Intra-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable technique comments for the next procedure.", "quick_options": ["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."]}, {"section": "Recommended next procedure", "key": "next_procedure_post_procedure_comments", "label": "Post-procedure comments", "default_layer": "Per-Form Default", "input_type": "textarea", "required": false, "options": "", "help": "Editable follow-up and aftercare comments for the next procedure.", "quick_options": ["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."]}], "narrative_template": "Procedure: Basivertebral nerve ablation / Intracept procedure documentation\nIndication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}} Baseline pain/function: {{baseline_pain_function}}.\n\nConsent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}\n\nSetup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}\n\nGuidance: {{guidance}}. {{guidance_phrase}} Images: {{image_saved}}\n\nTechnique: Using {{transducer_or_equipment}}, a {{needle}} was advanced via {{approach}} to {{target}} at {{levels_targets}}. Needle visualization/path: {{needle_visualization}} Safety check/aspiration/stimulation: {{aspiration_result}} Treatment character/spread/response: {{injection_character}}\n\nMedication / device: {{injectate_product}} Dose/volume/settings: {{dose_volume}} Medication mix/diluent: {{diluent_anesthetic}} Total delivered: {{total_volume}} Lot/expiry/device ID: {{lot_expiry}}\n\nOutcome: {{immediate_response}} Complications/adverse event: {{complications}}\n\nDisposition: {{post_procedure_instructions}} {{follow_up_plan}}\n\nRecommended 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}}.", "navigator": {"region": "Lumbar spine", "guidance_options": ["Fluoroscopy-guided"], "intervention_type": "Ablation / PRF", "procedure_group": "Basivertebral nerve ablation (Intracept)", "condition": "Lumbar facet-mediated pain; Chronic post-surgical pain; Vertebrogenic low back pain / Modic change-associated pain"}}], "conditions": [{"condition_id": "knee_osteoarthritis", "condition": "Knee osteoarthritis / chronic knee pain", "history_form_id": "hist_knee_osteoarthritis", "exam_form_id": "exam_knee_osteoarthritis", "procedure_ids": ["knee_ia_steroid_us", "knee_ia_ha_us", "knee_ia_prp_us", "knee_periarticular_prolo_us", "genicular_rfa", "patellar_tendon_prp_us", "saphenous_adductor_canal_block_us", "femoral_nerve_block_us", "genicular_nerve_block_us", "genicular_prf_us", "peripheral_nerve_stimulation_trial_us", "sprint_or_pns_followup_programming"], "prompts": "Mechanical symptoms, effusion, stair tolerance, gait aid use, prior arthroplasty status.", "navigator": {"region": "Knee", "condition": "Knee osteoarthritis / chronic knee pain", "pain_generator": "Joint / facet"}}, {"condition_id": "hip_osteoarthritis", "condition": "Hip osteoarthritis / chronic groin pain", "history_form_id": "hist_hip_osteoarthritis", "exam_form_id": "exam_hip_osteoarthritis", "procedure_ids": ["hip_ia_steroid_us", "hip_ia_prp_us", "hip_ha_us", "hip_periarticular_prolo_us", "obturator_nerve_block_us", "femoral_nerve_block_us", "pengi_block_us", "hip_articular_branch_block_us", "hip_articular_branch_rfa"], "prompts": "Groin vs lateral pain, mechanical limitation, walking distance, prior imaging.", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Hip osteoarthritis / chronic groin pain", "pain_generator": "Joint / facet"}}, {"condition_id": "shoulder_oa_capsulitis", "condition": "Shoulder osteoarthritis / adhesive capsulitis", "history_form_id": "hist_shoulder_oa_capsulitis", "exam_form_id": "exam_shoulder_oa_capsulitis", "procedure_ids": ["shoulder_gh_steroid_us", "shoulder_capsular_hydrodilatation_us", "suprascapular_nerve_block_us", "shoulder_ha_us", "shoulder_articular_branch_block_us", "shoulder_articular_branch_rfa", "suprascapular_nerve_rfa_us", "peripheral_nerve_stimulation_trial_us", "sprint_or_pns_followup_programming"], "prompts": "Passive range limitation, capsular pattern, night pain, diabetes/thyroid association.", "navigator": {"region": "Shoulder", "condition": "Shoulder osteoarthritis / adhesive capsulitis", "pain_generator": "Joint / facet"}}, {"condition_id": "rotator_cuff_subacromial", "condition": "Rotator cuff tendinopathy / subacromial pain", "history_form_id": "hist_rotator_cuff_subacromial", "exam_form_id": "exam_rotator_cuff_subacromial", "procedure_ids": ["shoulder_subacromial_steroid_us", "shoulder_tendon_prp_us", "suprascapular_nerve_block_us", "biceps_tendon_sheath_steroid_us", "shoulder_articular_branch_block_us", "shoulder_articular_branch_rfa", "suprascapular_nerve_rfa_us"], "prompts": "Painful arc, weakness pattern, night pain, overhead activity limitation.", "navigator": {"region": "Shoulder", "condition": "Rotator cuff tendinopathy / subacromial pain", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "ac_joint_arthropathy", "condition": "Acromioclavicular joint arthropathy", "history_form_id": "hist_ac_joint_arthropathy", "exam_form_id": "exam_ac_joint_arthropathy", "procedure_ids": ["ac_joint_steroid_us"], "prompts": "Cross-body adduction pain, superior shoulder pain, trauma history.", "navigator": {"region": "Shoulder", "condition": "Acromioclavicular joint arthropathy", "pain_generator": "Joint / facet"}}, {"condition_id": "biceps_tendinopathy", "condition": "Long head biceps tendinopathy", "history_form_id": "hist_biceps_tendinopathy", "exam_form_id": "exam_biceps_tendinopathy", "procedure_ids": ["shoulder_tendon_prp_us", "biceps_tendon_sheath_steroid_us"], "prompts": "Anterior shoulder pain, lifting/supination provocation, pulley instability symptoms.", "navigator": {"region": "Shoulder", "condition": "Long head biceps tendinopathy", "pain_generator": "Tendon / enthesis"}}, {"condition_id": "gtps", "condition": "Greater trochanteric pain syndrome", "history_form_id": "hist_gtps", "exam_form_id": "exam_gtps", "procedure_ids": ["gt_bursa_gluteal_tendon_steroid_us", "hip_periarticular_prolo_us", "greater_trochanter_prp_us"], "prompts": "Lateral hip pain, side-lying intolerance, gluteal weakness, lumbar overlap.", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Greater trochanteric pain syndrome", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "piriformis_deep_gluteal", "condition": "Piriformis / deep gluteal pain", "history_form_id": "hist_piriformis_deep_gluteal", "exam_form_id": "exam_piriformis_deep_gluteal", "procedure_ids": ["piriformis_injection_us"], "prompts": "Buttock pain, sitting intolerance, sciatic-like symptoms, hip rotation provocation.", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Piriformis / deep gluteal pain", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "sacroiliac_joint_pain", "condition": "Sacroiliac joint pain / posterior pelvic pain", "history_form_id": "hist_sacroiliac_joint_pain", "exam_form_id": "exam_sacroiliac_joint_pain", "procedure_ids": ["si_joint_steroid_us", "si_ligament_prolo_us", "quadratus_lumborum_block_us"], "prompts": "PSIS-region pain, Fortin area, provocation tests, pregnancy/trauma history.", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Sacroiliac joint pain / posterior pelvic pain", "pain_generator": "Joint / facet"}}, {"condition_id": "lumbar_facet_pain", "condition": "Lumbar facet-mediated pain", "history_form_id": "hist_lumbar_facet_pain", "exam_form_id": "exam_lumbar_facet_pain", "procedure_ids": ["lumbar_mbb", "lumbar_medial_branch_rfa", "facet_intraarticular_lumbar_steroid", "lumbar_facet_mbb_us", "lumbar_paravertebral_block_us", "tlip_block_us", "erector_spinae_plane_block_us", "quadratus_lumborum_block_us", "basivertebral_nerve_ablation_intracept_template"], "prompts": "Extension/rotation pain, axial predominance, diagnostic block history.", "navigator": {"region": "Lumbar spine", "condition": "Lumbar facet-mediated pain", "pain_generator": "Joint / facet"}}, {"condition_id": "cervical_facet_pain", "condition": "Cervical facet-mediated pain", "history_form_id": "hist_cervical_facet_pain", "exam_form_id": "exam_cervical_facet_pain", "procedure_ids": ["cervical_mbb", "cervical_medial_branch_rfa", "facet_intraarticular_cervical_steroid", "cervical_mbb_us", "cervical_third_occipital_nerve_block_us"], "prompts": "Axial neck pain, headache referral, rotation/extension triggers.", "navigator": {"region": "Cervical spine / head", "condition": "Cervical facet-mediated pain", "pain_generator": "Joint / facet"}}, {"condition_id": "thoracic_facet_rib_pain", "condition": "Thoracic facet / rib / chest wall pain", "history_form_id": "hist_thoracic_facet_rib_pain", "exam_form_id": "exam_thoracic_facet_rib_pain", "procedure_ids": ["thoracic_mbb", "thoracic_medial_branch_rfa", "intercostal_nerve_block_us", "erector_spinae_plane_block_us", "thoracic_paravertebral_block_us", "serratus_anterior_plane_block_us", "rhomboid_intercostal_plane_block_us"], "prompts": "Thoracic axial pain, rib referral, respiratory/movement provocation.", "navigator": {"region": "Thoracic spine / chest wall", "condition": "Thoracic facet / rib / chest wall pain", "pain_generator": "Joint / facet"}}, {"condition_id": "lumbar_radiculopathy", "condition": "Lumbar radicular pain / sciatica", "history_form_id": "hist_lumbar_radiculopathy", "exam_form_id": "exam_lumbar_radiculopathy", "procedure_ids": ["tf_snerb_esi_fluoro", "caudal_esi_fluoro", "lumbar_interlaminar_esi_us", "caudal_esi_us", "lumbar_selective_nerve_root_block_us", "lumbar_paravertebral_block_us", "tlip_block_us", "scs_trial_followup_template"], "prompts": "Dermatomal pain, neurologic symptoms, imaging-level correlation, red flags.", "navigator": {"region": "Lumbar spine", "condition": "Lumbar radicular pain / sciatica", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "cervical_radiculopathy", "condition": "Cervical radicular pain", "history_form_id": "hist_cervical_radiculopathy", "exam_form_id": "exam_cervical_radiculopathy", "procedure_ids": ["cervical_esi_fluoro", "cervical_selective_nerve_root_block_us"], "prompts": "Arm pain distribution, neurologic symptoms, imaging correlation, myelopathy screen.", "navigator": {"region": "Cervical spine / head", "condition": "Cervical radicular pain", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "myofascial_pain", "condition": "Myofascial pain syndrome", "history_form_id": "hist_myofascial_pain", "exam_form_id": "exam_myofascial_pain", "procedure_ids": ["trigger_point_injections", "tlip_block_us"], "prompts": "Trigger points, taut bands, postural/occupational factors, sleep and stress.", "navigator": {"region": "General / multisite pain", "condition": "Myofascial pain syndrome", "pain_generator": "Tendon / enthesis"}}, {"condition_id": "occipital_neuralgia", "condition": "Occipital neuralgia / cervicogenic headache", "history_form_id": "hist_occipital_neuralgia", "exam_form_id": "exam_occipital_neuralgia", "procedure_ids": ["occipital_nerve_block_us", "cervical_mbb", "cervical_mbb_us", "cervical_third_occipital_nerve_block_us", "occipital_nerve_prf_us", "supratrochlear_supraorbital_block_us"], "prompts": "Headache distribution, allodynia, neck triggers, migraine overlap.", "navigator": {"region": "Cervical spine / head", "condition": "Occipital neuralgia / cervicogenic headache", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "carpal_tunnel", "condition": "Carpal tunnel syndrome", "history_form_id": "hist_carpal_tunnel", "exam_form_id": "exam_carpal_tunnel", "procedure_ids": ["median_nerve_hydrodissection_us", "carpal_tunnel_steroid_us"], "prompts": "Median sensory symptoms, nocturnal symptoms, thenar weakness, EMG/imaging.", "navigator": {"region": "Wrist / hand", "condition": "Carpal tunnel syndrome", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "dequervain", "condition": "De Quervain tenosynovitis", "history_form_id": "hist_dequervain", "exam_form_id": "exam_dequervain", "procedure_ids": ["dequervain_sheath_steroid_us"], "prompts": "Radial wrist pain, thumb use, postpartum/overuse context.", "navigator": {"region": "Wrist / hand", "condition": "De Quervain tenosynovitis", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "thumb_cmc_oa", "condition": "Thumb CMC osteoarthritis", "history_form_id": "hist_thumb_cmc_oa", "exam_form_id": "exam_thumb_cmc_oa", "procedure_ids": ["thumb_cmc_steroid_us", "first_cmc_steroid_us"], "prompts": "Pinch/grip pain, basal thumb deformity, brace/hand therapy response.", "navigator": {"region": "Wrist / hand", "condition": "Thumb CMC osteoarthritis", "pain_generator": "Joint / facet"}}, {"condition_id": "trigger_finger", "condition": "Trigger finger / stenosing tenosynovitis", "history_form_id": "hist_trigger_finger", "exam_form_id": "exam_trigger_finger", "procedure_ids": ["trigger_finger_steroid_us"], "prompts": "Triggering/locking, digit involved, diabetes association, prior injections.", "navigator": {"region": "Wrist / hand", "condition": "Trigger finger / stenosing tenosynovitis", "pain_generator": "Myofascial / central sensitization"}}, {"condition_id": "lateral_epicondylalgia", "condition": "Lateral epicondylalgia", "history_form_id": "hist_lateral_epicondylalgia", "exam_form_id": "exam_lateral_epicondylalgia", "procedure_ids": ["elbow_lateral_epicondyle_prp_us", "elbow_lateral_epicondyle_prolo_us"], "prompts": "Grip pain, resisted wrist extension pain, work/sport load.", "navigator": {"region": "Elbow", "condition": "Lateral epicondylalgia", "pain_generator": "Tendon / enthesis"}}, {"condition_id": "medial_epicondylalgia", "condition": "Medial epicondylalgia", "history_form_id": "hist_medial_epicondylalgia", "exam_form_id": "exam_medial_epicondylalgia", "procedure_ids": ["medial_epicondyle_prp_us"], "prompts": "Flexor-pronator load, ulnar nerve symptoms, throwing/golf history.", "navigator": {"region": "Elbow", "condition": "Medial epicondylalgia", "pain_generator": "Tendon / enthesis"}}, {"condition_id": "plantar_fasciopathy", "condition": "Plantar fasciopathy", "history_form_id": "hist_plantar_fasciopathy", "exam_form_id": "exam_plantar_fasciopathy", "procedure_ids": ["plantar_fascia_prp_us", "plantar_fascia_steroid_us", "plantar_fascia_prolo_us"], "prompts": "First-step pain, footwear, calf tightness, activity load.", "navigator": {"region": "Foot / ankle", "condition": "Plantar fasciopathy", "pain_generator": "Tendon / enthesis"}}, {"condition_id": "achilles_tendinopathy", "condition": "Achilles tendinopathy", "history_form_id": "hist_achilles_tendinopathy", "exam_form_id": "exam_achilles_tendinopathy", "procedure_ids": ["achilles_tendon_prp_us"], "prompts": "Midportion vs insertional pain, tendon thickening, load history.", "navigator": {"region": "Foot / ankle", "condition": "Achilles tendinopathy", "pain_generator": "Tendon / enthesis"}}, {"condition_id": "patellar_tendinopathy", "condition": "Patellar tendinopathy", "history_form_id": "hist_patellar_tendinopathy", "exam_form_id": "exam_patellar_tendinopathy", "procedure_ids": ["patellar_tendon_prp_us"], "prompts": "Anterior knee tendon pain, jumping/squat load, tendon imaging.", "navigator": {"region": "Knee", "condition": "Patellar tendinopathy", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "ankle_osteoarthritis", "condition": "Ankle osteoarthritis", "history_form_id": "hist_ankle_osteoarthritis", "exam_form_id": "exam_ankle_osteoarthritis", "procedure_ids": ["ankle_joint_steroid_us", "ankle_joint_ha_us", "ankle_prp_us"], "prompts": "Post-traumatic history, instability, walking tolerance, swelling.", "navigator": {"region": "Foot / ankle", "condition": "Ankle osteoarthritis", "pain_generator": "Joint / facet"}}, {"condition_id": "mortons_neuroma", "condition": "Morton neuroma / forefoot neuralgia", "history_form_id": "hist_mortons_neuroma", "exam_form_id": "exam_mortons_neuroma", "procedure_ids": ["mortons_neuroma_injection_us", "tibial_nerve_block_us"], "prompts": "Interdigital burning, shoe intolerance, Mulder symptoms.", "navigator": {"region": "Foot / ankle", "condition": "Morton neuroma / forefoot neuralgia", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "coccydynia", "condition": "Coccydynia", "history_form_id": "hist_coccydynia", "exam_form_id": "exam_coccydynia", "procedure_ids": ["coccyx_ganglion_impar_block_fluoro", "coccygeal_ligament_injection_us", "ganglion_impar_us"], "prompts": "Sitting pain, trauma/childbirth history, bowel/pelvic symptoms.", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Coccydynia", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "intercostal_neuralgia", "condition": "Intercostal neuralgia / post-thoracotomy pain", "history_form_id": "hist_intercostal_neuralgia", "exam_form_id": "exam_intercostal_neuralgia", "procedure_ids": ["intercostal_nerve_block_us", "erector_spinae_plane_block_us", "thoracic_paravertebral_block_us", "serratus_anterior_plane_block_us", "pecs_block_us", "rhomboid_intercostal_plane_block_us"], "prompts": "Dermatomal chest wall pain, surgery/trauma/zoster history.", "navigator": {"region": "Thoracic spine / chest wall", "condition": "Intercostal neuralgia / post-thoracotomy pain", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "ilioinguinal_neuralgia", "condition": "Ilioinguinal/iliohypogastric/genitofemoral neuralgia", "history_form_id": "hist_ilioinguinal_neuralgia", "exam_form_id": "exam_ilioinguinal_neuralgia", "procedure_ids": ["ilioinguinal_iliohypogastric_block_us", "genitofemoral_block_us", "transversus_abdominis_plane_block_us", "peripheral_nerve_prf_us"], "prompts": "Groin/lower abdominal neuralgia, surgery history, sensory territory.", "navigator": {"region": "General / multisite pain", "condition": "Ilioinguinal/iliohypogastric/genitofemoral neuralgia", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "pudendal_neuralgia", "condition": "Pudendal neuralgia / pelvic pain", "history_form_id": "hist_pudendal_neuralgia", "exam_form_id": "exam_pudendal_neuralgia", "procedure_ids": ["pudendal_nerve_block_us", "coccyx_ganglion_impar_block_fluoro", "ganglion_impar_us", "superior_hypogastric_plexus_block_us"], "prompts": "Perineal pain, sitting intolerance, bladder/bowel/sexual symptoms.", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Pudendal neuralgia / pelvic pain", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "cluneal_neuralgia", "condition": "Superior cluneal neuralgia", "history_form_id": "hist_cluneal_neuralgia", "exam_form_id": "exam_cluneal_neuralgia", "procedure_ids": ["superior_cluneal_nerve_block_us", "peripheral_nerve_prf_us", "peripheral_nerve_stimulation_trial_us", "sprint_or_pns_followup_programming"], "prompts": "Iliac crest trigger point, low back/buttock referral.", "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Superior cluneal neuralgia", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "crps", "condition": "Complex regional pain syndrome", "history_form_id": "hist_crps", "exam_form_id": "exam_crps", "procedure_ids": ["stellate_ganglion_block_us", "ketamine_infusion_chronic_pain", "lumbar_sympathetic_block_us", "scs_trial_followup_template", "dorsal_root_ganglion_stimulation_template"], "prompts": "Budapest criteria features, autonomic/trophic changes, limb function.", "navigator": {"region": "General / multisite pain", "condition": "Complex regional pain syndrome", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "peripheral_neuropathic_pain", "condition": "Peripheral neuropathic pain / post-herpetic neuralgia", "history_form_id": "hist_peripheral_neuropathic_pain", "exam_form_id": "exam_peripheral_neuropathic_pain", "procedure_ids": ["trigger_point_injections", "intercostal_nerve_block_us", "ketamine_infusion_chronic_pain", "lateral_femoral_cutaneous_block_us", "saphenous_adductor_canal_block_us", "peroneal_nerve_block_us", "tibial_nerve_block_us", "supratrochlear_supraorbital_block_us", "auriculotemporal_block_us", "trigeminal_branch_block_us", "stellate_ganglion_block_us", "lumbar_sympathetic_block_us", "obturator_nerve_block_us", "femoral_nerve_block_us", "peripheral_nerve_prf_us", "peripheral_nerve_stimulation_trial_us", "sprint_or_pns_followup_programming", "scs_trial_followup_template", "dorsal_root_ganglion_stimulation_template"], "prompts": "Allodynia, sensory changes, zoster/diabetes/trauma context.", "navigator": {"region": "General / multisite pain", "condition": "Peripheral neuropathic pain / post-herpetic neuralgia", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "fibromyalgia_central_sensitization", "condition": "Fibromyalgia / central sensitization", "history_form_id": "hist_fibromyalgia_central_sensitization", "exam_form_id": "exam_fibromyalgia_central_sensitization", "procedure_ids": ["ketamine_infusion_chronic_pain", "trigger_point_injections"], "prompts": "Widespread pain, fatigue, sleep, mood, cognitive symptoms.", "navigator": {"region": "Central sensitization / infusion", "condition": "Fibromyalgia / central sensitization", "pain_generator": "Myofascial / central sensitization"}}, {"condition_id": "chronic_post_surgical_pain", "condition": "Chronic post-surgical pain", "history_form_id": "hist_chronic_post_surgical_pain", "exam_form_id": "exam_chronic_post_surgical_pain", "procedure_ids": ["trigger_point_injections", "intercostal_nerve_block_us", "ketamine_infusion_chronic_pain", "ilioinguinal_iliohypogastric_block_us", "genitofemoral_block_us", "thoracic_paravertebral_block_us", "serratus_anterior_plane_block_us", "pecs_block_us", "rhomboid_intercostal_plane_block_us", "superior_hypogastric_plexus_block_us", "erector_spinae_plane_block_us", "quadratus_lumborum_block_us", "transversus_abdominis_plane_block_us", "peripheral_nerve_prf_us", "peripheral_nerve_stimulation_trial_us", "sprint_or_pns_followup_programming", "scs_trial_followup_template", "dorsal_root_ganglion_stimulation_template", "basivertebral_nerve_ablation_intracept_template"], "prompts": "Surgery type, scar/allodynia, neuropathic features, functional impact.", "navigator": {"region": "General / multisite pain", "condition": "Chronic post-surgical pain", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "headache_cranial_neuralgia", "condition": "Headache / cranial neuralgia", "history_form_id": "hist_headache_cranial_neuralgia", "exam_form_id": "exam_headache_cranial_neuralgia", "procedure_ids": ["cervical_third_occipital_nerve_block_us", "occipital_nerve_prf_us", "supratrochlear_supraorbital_block_us", "auriculotemporal_block_us", "trigeminal_branch_block_us"], "navigator": {"region": "Cervical spine / head", "condition": "Headache / cranial neuralgia", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "trigeminal_neuralgia_facial_pain", "condition": "Trigeminal neuralgia / facial neuropathic pain", "history_form_id": "hist_trigeminal_neuralgia_facial_pain", "exam_form_id": "exam_trigeminal_neuralgia_facial_pain", "procedure_ids": ["trigeminal_branch_block_us", "auriculotemporal_block_us", "ketamine_infusion_chronic_pain"], "navigator": {"region": "General / multisite pain", "condition": "Trigeminal neuralgia / facial neuropathic pain", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "post_mastectomy_chest_wall_pain", "condition": "Post-mastectomy / post-thoracotomy chest wall pain", "history_form_id": "hist_post_mastectomy_chest_wall_pain", "exam_form_id": "exam_post_mastectomy_chest_wall_pain", "procedure_ids": ["intercostal_nerve_block_us", "thoracic_paravertebral_block_us", "serratus_anterior_plane_block_us", "pecs_block_us", "rhomboid_intercostal_plane_block_us", "peripheral_nerve_stimulation_trial_us"], "navigator": {"region": "Thoracic spine / chest wall", "condition": "Post-mastectomy / post-thoracotomy chest wall pain", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "meralgia_paresthetica", "condition": "Meralgia paresthetica / lateral femoral cutaneous neuralgia", "history_form_id": "hist_meralgia_paresthetica", "exam_form_id": "exam_meralgia_paresthetica", "procedure_ids": ["lateral_femoral_cutaneous_block_us", "peripheral_nerve_prf_us", "peripheral_nerve_stimulation_trial_us"], "navigator": {"region": "General / multisite pain", "condition": "Meralgia paresthetica / lateral femoral cutaneous neuralgia", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "tarsal_tunnel_tibial_neuralgia", "condition": "Tarsal tunnel syndrome / tibial neuralgia", "history_form_id": "hist_tarsal_tunnel_tibial_neuralgia", "exam_form_id": "exam_tarsal_tunnel_tibial_neuralgia", "procedure_ids": ["tibial_nerve_block_us", "peripheral_nerve_prf_us", "peripheral_nerve_stimulation_trial_us"], "navigator": {"region": "Foot / ankle", "condition": "Tarsal tunnel syndrome / tibial neuralgia", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "peroneal_neuralgia", "condition": "Common peroneal neuralgia / lateral leg neuropathic pain", "history_form_id": "hist_peroneal_neuralgia", "exam_form_id": "exam_peroneal_neuralgia", "procedure_ids": ["peroneal_nerve_block_us", "peripheral_nerve_prf_us", "peripheral_nerve_stimulation_trial_us"], "navigator": {"region": "General / multisite pain", "condition": "Common peroneal neuralgia / lateral leg neuropathic pain", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "saphenous_neuralgia", "condition": "Saphenous neuralgia / medial knee neuropathic pain", "history_form_id": "hist_saphenous_neuralgia", "exam_form_id": "exam_saphenous_neuralgia", "procedure_ids": ["saphenous_adductor_canal_block_us", "peripheral_nerve_prf_us", "peripheral_nerve_stimulation_trial_us"], "navigator": {"region": "Knee", "condition": "Saphenous neuralgia / medial knee neuropathic pain", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "obturator_neuralgia", "condition": "Obturator neuralgia / medial groin pain", "history_form_id": "hist_obturator_neuralgia", "exam_form_id": "exam_obturator_neuralgia", "procedure_ids": ["obturator_nerve_block_us", "peripheral_nerve_prf_us"], "navigator": {"region": "General / multisite pain", "condition": "Obturator neuralgia / medial groin pain", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "femoral_neuralgia", "condition": "Femoral neuralgia / anterior thigh neuropathic pain", "history_form_id": "hist_femoral_neuralgia", "exam_form_id": "exam_femoral_neuralgia", "procedure_ids": ["femoral_nerve_block_us", "peripheral_nerve_prf_us"], "navigator": {"region": "General / multisite pain", "condition": "Femoral neuralgia / anterior thigh neuropathic pain", "pain_generator": "Neuropathic / nerve"}}, {"condition_id": "vertebrogenic_low_back_pain", "condition": "Vertebrogenic low back pain / Modic change-associated pain", "history_form_id": "hist_vertebrogenic_low_back_pain", "exam_form_id": "exam_vertebrogenic_low_back_pain", "procedure_ids": ["basivertebral_nerve_ablation_intracept_template", "trigger_point_injections"], "navigator": {"region": "Lumbar spine", "condition": "Vertebrogenic low back pain / Modic change-associated pain", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "failed_back_surgery_syndrome", "condition": "Failed back surgery syndrome / persistent spinal pain syndrome", "history_form_id": "hist_failed_back_surgery_syndrome", "exam_form_id": "exam_failed_back_surgery_syndrome", "procedure_ids": ["caudal_esi_us", "caudal_esi_fluoro", "lumbar_paravertebral_block_us", "tlip_block_us", "scs_trial_followup_template", "dorsal_root_ganglion_stimulation_template", "ketamine_infusion_chronic_pain"], "navigator": {"region": "General / multisite pain", "condition": "Failed back surgery syndrome / persistent spinal pain syndrome", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "phantom_limb_stump_pain", "condition": "Phantom limb pain / stump pain", "history_form_id": "hist_phantom_limb_stump_pain", "exam_form_id": "exam_phantom_limb_stump_pain", "procedure_ids": ["peripheral_nerve_prf_us", "peripheral_nerve_stimulation_trial_us", "ketamine_infusion_chronic_pain"], "navigator": {"region": "General / multisite pain", "condition": "Phantom limb pain / stump pain", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "post_herniorrhaphy_groin_pain", "condition": "Post-herniorrhaphy groin pain", "history_form_id": "hist_post_herniorrhaphy_groin_pain", "exam_form_id": "exam_post_herniorrhaphy_groin_pain", "procedure_ids": ["ilioinguinal_iliohypogastric_block_us", "genitofemoral_block_us", "peripheral_nerve_prf_us", "peripheral_nerve_stimulation_trial_us"], "navigator": {"region": "General / multisite pain", "condition": "Post-herniorrhaphy groin pain", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "abdominal_wall_pain", "condition": "Abdominal wall pain / ACNES / post-surgical abdominal wall pain", "history_form_id": "hist_abdominal_wall_pain", "exam_form_id": "exam_abdominal_wall_pain", "procedure_ids": ["transversus_abdominis_plane_block_us", "ilioinguinal_iliohypogastric_block_us", "genitofemoral_block_us", "peripheral_nerve_prf_us", "peripheral_nerve_stimulation_trial_us"], "navigator": {"region": "General / multisite pain", "condition": "Abdominal wall pain / ACNES / post-surgical abdominal wall pain", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "sympathetically_maintained_pain", "condition": "Sympathetically maintained pain", "history_form_id": "hist_sympathetically_maintained_pain", "exam_form_id": "exam_sympathetically_maintained_pain", "procedure_ids": ["stellate_ganglion_block_us", "lumbar_sympathetic_block_us", "peripheral_nerve_prf_us", "ketamine_infusion_chronic_pain"], "navigator": {"region": "General / multisite pain", "condition": "Sympathetically maintained pain", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "flank_pain_regional_pain", "condition": "Flank pain / thoracolumbar regional pain", "history_form_id": "hist_flank_pain_regional_pain", "exam_form_id": "exam_flank_pain_regional_pain", "procedure_ids": ["quadratus_lumborum_block_us", "erector_spinae_plane_block_us", "tlip_block_us", "trigger_point_injections"], "navigator": {"region": "Lumbar spine", "condition": "Flank pain / thoracolumbar regional pain", "pain_generator": "Mixed / regional pain"}}, {"condition_id": "pelvic_visceral_pain", "condition": "Chronic pelvic / visceral pelvic pain", "history_form_id": "hist_pelvic_visceral_pain", "exam_form_id": "exam_pelvic_visceral_pain", "procedure_ids": ["pudendal_nerve_block_us", "ganglion_impar_us", "coccyx_ganglion_impar_block_fluoro", "superior_hypogastric_plexus_block_us", "ketamine_infusion_chronic_pain"], "navigator": {"region": "Pelvis / sacroiliac / hip", "condition": "Chronic pelvic / visceral pelvic pain", "pain_generator": "Mixed / regional pain"}}], "product_library": {"version": "v0.6", "created_for": "Epione Pain Centre", "warning": "Product/device entries are verification-backed picklist candidates, not certifications of active authorization. Verify DPD/MDALL and product labels before stocking/use.", "product_rows": [["STEROID_TRIAMCINOLONE", "Medication", "Injectable corticosteroid", "Triamcinolone acetonide injection", "Triamcinolone acetonide", "Common pain-clinic product class; concentration varies by DIN/manufacturer", "Joint/bursa/tendon sheath steroid procedures", "injectate_product;steroid_product;dose_volume", "Health Canada DPD", "VERIFY_ACTIVE_DPD_DIN", "Can be clinic/procedure default only after DIN/product verification", "Drug name, concentration, dose mg, volume mL, lot, expiry, route/site", "Search DPD by product/active ingredient; record DIN and marketed/dormant status; review monograph/label", "https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/drug-product-database.html", "Do not hard-code as active without DPD check."], ["STEROID_METHYLPRED", "Medication", "Injectable corticosteroid", "Methylprednisolone acetate injection", "Methylprednisolone acetate", "Depot corticosteroid product class; concentration varies", "Joint/bursa/tendon sheath steroid procedures", "injectate_product;steroid_product;dose_volume", "Health Canada DPD", "VERIFY_ACTIVE_DPD_DIN", "Can be clinic/procedure default only after DIN/product verification", "Drug name, concentration, dose mg, volume mL, lot, expiry, route/site", "Search DPD by product/active ingredient; record DIN and marketed/dormant status; review monograph/label", "https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/drug-product-database.html", "Use product-specific wording once stocked."], ["STEROID_DEXAMETHASONE", "Medication", "Injectable corticosteroid", "Dexamethasone sodium phosphate injection", "Dexamethasone sodium phosphate", "Non-particulate corticosteroid product class; concentration varies", "Selected spine/perineural procedures where non-particulate steroid is selected by physician", "injectate_product;steroid_product;dose_volume", "Health Canada DPD", "VERIFY_ACTIVE_DPD_DIN", "Can be procedure default where clinically selected; must verify product/DIN", "Drug name, concentration, dose mg, volume mL, lot, expiry, route/site", "Search DPD; record DIN/status; confirm preservative status and monograph", "https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/drug-product-database.html", "Selection is physician-specific and indication-specific."], ["STEROID_BETAMETHASONE", "Medication", "Injectable corticosteroid", "Betamethasone injectable preparations", "Betamethasone compounds", "Injectable corticosteroid product class; product formulations vary", "Alternative steroid picklist", "injectate_product;steroid_product;dose_volume", "Health Canada DPD", "VERIFY_ACTIVE_DPD_DIN", "Optional clinic default only if stocked and verified", "Drug name, concentration, dose mg, volume mL, lot, expiry, route/site", "Search DPD; record DIN/status; confirm formulation", "https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/drug-product-database.html", "Do not assume interchangeability across formulations."], ["LA_LIDOCAINE", "Medication", "Local anesthetic", "Lidocaine injection", "Lidocaine hydrochloride", "1% or 2% commonly used; product-specific concentration/preservative status varies", "Local anesthetic/diluent in injections, blocks, hydrodissection", "diluent_anesthetic;local_anesthetic_product;local_anesthetic_volume", "Health Canada DPD", "VERIFY_ACTIVE_DPD_DIN", "Global default permitted only as class/placeholder; product-specific default after verification", "Drug name, concentration, preservative status, volume, lot, expiry", "Search DPD; verify concentration/preservative status and manufacturer", "https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/drug-product-database.html", "Use preservative-free where clinically indicated and stocked."], ["LA_BUPIVACAINE", "Medication", "Local anesthetic", "Bupivacaine injection", "Bupivacaine hydrochloride", "0.25% or 0.5% product-specific concentration", "Longer-acting local anesthetic for selected blocks/procedures", "diluent_anesthetic;local_anesthetic_product;local_anesthetic_volume", "Health Canada DPD", "VERIFY_ACTIVE_DPD_DIN", "Optional global/procedure default after verification", "Drug name, concentration, preservative status, volume, lot, expiry", "Search DPD; verify concentration/preservative status and contraindications", "https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/drug-product-database.html", "Clinic policy should specify maximum dose safeguards."], ["LA_ROPIVACAINE", "Medication", "Local anesthetic", "Ropivacaine injection", "Ropivacaine hydrochloride", "Product-specific concentration", "Selected peripheral nerve/fascial plane blocks", "diluent_anesthetic;local_anesthetic_product;local_anesthetic_volume", "Health Canada DPD", "VERIFY_ACTIVE_DPD_DIN", "Optional procedure default after verification", "Drug name, concentration, preservative status, volume, lot, expiry", "Search DPD and confirm stock status", "https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/drug-product-database.html", "Useful as a picklist option, not hard-coded default."], ["SALINE_PF", "Medication/Solution", "Diluent / hydrodissection", "Preservative-free normal saline", "Sodium chloride", "Sterile injectable solution; product-specific presentation", "Hydrodissection, dilution, flushes", "diluent;hydrodissection_solution;saline_volume", "Health Canada DPD / product label", "VERIFY_STOCK_AND_LABEL", "Global/procedure default allowed if product verified", "Product, concentration, volume, lot, expiry", "Verify sterile injectable product label and supply chain", "https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/drug-product-database.html", "Document if used as diluent or hydrodissection component."], ["DEXTROSE_PROLO", "Medication/Solution", "Prolotherapy solution", "Dextrose solution for injection / compounded prolotherapy solution", "Dextrose", "Concentration varies by clinic protocol/compounding", "Prolotherapy templates", "prolo_solution;dextrose_concentration;total_volume", "Health Canada DPD / compounding policy", "VERIFY_PRODUCT_OR_COMPOUNDING", "Procedure-specific default only after clinic protocol review", "Concentration, total volume, diluent, local anesthetic, lot/expiry/source", "Verify commercial product or compounding process; record lot/source/expiry", "https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/drug-product-database.html", "Treat as high-governance default; no automatic patient-specific default for exact amount."], ["HA_SYNVISC", "Medical device/viscosupplement", "Hyaluronic acid", "Synvisc / Synvisc-One class", "Hylan G-F 20", "Single- or multi-injection viscosupplement presentations", "Knee/ankle HA forms", "ha_product;ha_volume;injectate_product", "Health Canada MDALL", "VERIFY_ACTIVE_MDALL_DEVICE", "Procedure default only after licence/device name verification", "Product/device name, volume, lot, expiry, laterality/site", "Search MDALL by device/licence name; record licence/device name/status; confirm package insert", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Names included as common market examples; verify current licensing before use."], ["HA_DUROLANE", "Medical device/viscosupplement", "Hyaluronic acid", "Durolane class", "Sodium hyaluronate", "Single-injection viscosupplement presentation", "Knee/ankle HA forms", "ha_product;ha_volume;injectate_product", "Health Canada MDALL", "VERIFY_ACTIVE_MDALL_DEVICE", "Procedure default only after MDALL verification", "Product/device name, volume, lot, expiry, laterality/site", "Search MDALL by device/licence name; record licence/device name/status; confirm package insert", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Use exact stocked product wording."], ["HA_MONOVISC", "Medical device/viscosupplement", "Hyaluronic acid", "Monovisc class", "Sodium hyaluronate", "Single-injection viscosupplement presentation", "Knee/ankle HA forms", "ha_product;ha_volume;injectate_product", "Health Canada MDALL", "VERIFY_ACTIVE_MDALL_DEVICE", "Procedure default only after MDALL verification", "Product/device name, volume, lot, expiry, laterality/site", "Search MDALL by device/licence name; record licence/device name/status; confirm package insert", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Use exact stocked product wording."], ["HA_CINGAL", "Medical device/viscosupplement", "Hyaluronic acid combination product", "Cingal class", "Hyaluronic acid + corticosteroid component depending product labeling", "Combination viscosupplement; presentation product-specific", "Knee HA or combination injection forms", "ha_product;ha_volume;injectate_product;steroid_component", "Health Canada MDALL / DPD if applicable", "VERIFY_MDALL_AND_LABEL", "No global default; procedure default only after product verification", "Device/product, component(s), volume, lot, expiry", "Search MDALL; confirm labeling and whether steroid component requires additional drug documentation", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "High-priority verification item because it combines product categories."], ["HA_ORTHOVISC", "Medical device/viscosupplement", "Hyaluronic acid", "Orthovisc class", "Sodium hyaluronate", "Multi-injection viscosupplement presentation", "Knee/ankle HA forms", "ha_product;ha_volume;injectate_product", "Health Canada MDALL", "VERIFY_ACTIVE_MDALL_DEVICE", "Procedure default only after MDALL verification", "Product/device name, volume, lot, expiry, laterality/site", "Search MDALL by device/licence name; record licence/device name/status; confirm package insert", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Use exact stocked product wording."], ["HA_OSTENIL", "Medical device/viscosupplement", "Hyaluronic acid", "Ostenil / Ostenil Plus class", "Sodium hyaluronate", "Viscosupplement presentation product-specific", "Knee/ankle HA forms", "ha_product;ha_volume;injectate_product", "Health Canada MDALL", "VERIFY_ACTIVE_MDALL_DEVICE", "Procedure default only after MDALL verification", "Product/device name, volume, lot, expiry, laterality/site", "Search MDALL by device/licence name; record licence/device name/status; confirm package insert", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Use exact stocked product wording."], ["PRP_AUTOLOGOUS", "Autologous biologic/preparation", "PRP", "Autologous PRP prepared and administered in same procedure", "Patient autologous platelet-rich plasma", "Clinic protocol; kit-specific draw/spin/yield", "PRP forms", "prp_system;prp_protocol;prp_volume;blood_draw_volume", "Health Canada PRP clarification + device verification for kit", "PRACTICE_OF_MEDICINE_CONDITIONS_VERIFY", "No global product default; profile may default protocol prompts only", "Blood draw volume, anticoagulant if used, kit/system, spin protocol, PRP volume, lot/expiry for kit/disposables", "Confirm practitioner/patient/same-procedure conditions; verify PRP kit as device in MDALL/MDEL path as applicable", "https://recalls-rappels.canada.ca/en/alert-recall/health-canada-clarifies-position-platelet-rich-plasma-treatments", "Health Canada states PRP is drug but preparation can fall under practice of medicine/dentistry under specified conditions."], ["PRP_KIT_REGENLAB", "Medical device/disposable", "PRP kit/system", "RegenLab PRP kit class", "PRP preparation device/kit", "Kit-specific draw/spin/yield", "PRP procedure documentation", "prp_system;prp_protocol;prp_kit_lot", "Health Canada MDALL/MDEL as applicable", "VERIFY_ACTIVE_DEVICE_OR_SUPPLIER", "Procedure default only after device/supplier verification", "Kit name, lot, expiry, centrifuge protocol, anticoagulant, PRP yield", "Search MDALL/device listing and supplier documentation; record licence/device status", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Common market example; verify exact kit/version."], ["PRP_KIT_ARTHREX_ACP", "Medical device/disposable", "PRP kit/system", "Arthrex ACP class", "PRP preparation device/kit", "Kit-specific draw/spin/yield", "PRP procedure documentation", "prp_system;prp_protocol;prp_kit_lot", "Health Canada MDALL/MDEL as applicable", "VERIFY_ACTIVE_DEVICE_OR_SUPPLIER", "Procedure default only after device/supplier verification", "Kit name, lot, expiry, centrifuge protocol, anticoagulant, PRP yield", "Search MDALL/device listing and supplier documentation; record licence/device status", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Common market example; verify exact kit/version."], ["PRP_KIT_EMCYTE", "Medical device/disposable", "PRP kit/system", "EmCyte PurePRP class", "PRP preparation device/kit", "Kit-specific draw/spin/yield", "PRP procedure documentation", "prp_system;prp_protocol;prp_kit_lot", "Health Canada MDALL/MDEL as applicable", "VERIFY_ACTIVE_DEVICE_OR_SUPPLIER", "Procedure default only after device/supplier verification", "Kit name, lot, expiry, centrifuge protocol, anticoagulant, PRP yield", "Search MDALL/device listing and supplier documentation; record licence/device status", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Common market example; verify exact kit/version."], ["PRP_CENTRIFUGE", "Medical device/equipment", "PRP centrifuge", "Clinic PRP centrifuge", "Centrifuge system", "Device-specific speed/time protocol", "PRP forms", "centrifuge_model;prp_protocol", "Health Canada MDALL/MDEL/vendor documentation", "VERIFY_DEVICE_AND_PROTOCOL", "Procedure protocol default allowed once validated", "Centrifuge model, speed/time, rotor/tube, maintenance status", "Confirm device procurement, maintenance, and manufacturer protocol", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Include maintenance log outside EMR if applicable."], ["US_MACHINE", "Medical device/equipment", "Ultrasound machine", "Ultrasound system used for procedures", "Diagnostic ultrasound imaging system", "Clinic machine", "Ultrasound-guided procedures", "ultrasound_machine;guidance;guidance_phrase", "Health Canada MDALL", "VERIFY_ACTIVE_DEVICE_AND_MAINTENANCE", "Global default allowed for machine name after device verification", "Machine/probe, image saved/location, settings if relevant", "Search MDALL as Class II/III device; record machine and service status", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Do not need in every narrative if EMR/device record covers it, but image archive location matters."], ["RF_GENERATOR", "Medical device/equipment", "Radiofrequency generator", "RF generator for nerve ablation", "RF lesion generator", "Device model-specific settings", "RFA forms", "rfa_generator;rf_temperature_c;rf_duration_sec;rf_mode", "Health Canada MDALL", "VERIFY_ACTIVE_DEVICE_AND_MAINTENANCE", "Global/procedure default for model/settings after verification and protocol approval", "Generator model, mode, temperature, duration, cannula, sensory/motor testing, lesion count", "Search MDALL/device listing; record model; maintain calibration/service logs", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Settings are protocol defaults, not patient defaults; physician verifies each lesion."], ["RF_CANNULA", "Medical device/disposable", "RF cannula/electrode", "RF cannula and active tip", "RF electrode/cannula", "Gauge, length, active tip varies", "RFA forms", "rf_cannula;needle;active_tip;lesion_count", "Health Canada MDALL / supplier documentation", "VERIFY_DEVICE_AND_STOCK", "Procedure default allowed by form; exact needle lot/expiry manual", "Gauge, length, active tip, lot, expiry, lesion count", "Verify supplier, device status, package integrity, lot/expiry", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Exact lot/expiry remains No Default."], ["NEEDLE_ECHOGENIC", "Medical device/disposable", "Needle", "Echogenic block/injection needle", "Sterile needle", "Gauge/length varies", "US-guided injections/blocks", "needle;needle_gauge;needle_length", "Health Canada MDALL / Class I rules / supplier documentation", "VERIFY_DEVICE_CLASS_AND_STOCK", "Procedure default allowed for gauge/length; lot/expiry manual if documented", "Needle gauge/length/type; lot/expiry if required by clinic policy", "Confirm device class/licensing pathway and supplier", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Class I devices may not appear in MDALL; verify supply chain/MDEL."], ["SPINAL_NEEDLE", "Medical device/disposable", "Needle", "Spinal needle", "Sterile spinal needle", "Gauge/length varies", "Spine/fluoro procedures", "needle;needle_gauge;needle_length", "Health Canada MDALL / supplier documentation", "VERIFY_DEVICE_CLASS_AND_STOCK", "Procedure default allowed; exact lot/expiry manual if documented", "Needle gauge/length/type; lot/expiry if required", "Confirm device class/licensing pathway and supplier", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Do not assume product class in MDALL if Class I."], ["SYRINGE_STANDARD", "Medical device/disposable", "Syringe", "Sterile syringe", "Syringe", "1/3/5/10/20/60 mL presentations", "All procedures", "syringe;injectate_volume;total_volume", "Health Canada MDALL / MDEL supply chain", "VERIFY_STOCK_AND_SUPPLIER", "Global supply default; exact syringe usually not needed in narrative", "Lot/expiry if required by clinic policy or product tracking", "Confirm supplier and sterile stock process", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Operational inventory field, not always note field."], ["CONTRAST_NONIONIC", "Medication/contrast", "Contrast medium", "Non-ionic iodinated contrast", "Iodinated contrast agent", "Product-specific concentration/vial", "Fluoroscopy procedures", "contrast_product;contrast_volume;contrast_pattern", "Health Canada DPD", "VERIFY_ACTIVE_DPD_DIN", "Procedure default may specify class, exact product requires DPD", "Product, concentration, volume, lot, expiry, contrast pattern", "Search DPD; confirm contrast allergy/renal risk protocol", "https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/drug-product-database.html", "Contrast pattern remains manual-only."], ["KETAMINE", "Medication", "Infusion medication", "Ketamine injection", "Ketamine hydrochloride", "Product-specific concentration/vial", "Ketamine infusion chronic pain", "ketamine_product;ketamine_dose;infusion_rate;ketamine_concentration", "Health Canada DPD + controlled drug clinic policy", "VERIFY_ACTIVE_DPD_DIN_AND_CONTROLLED_DRUG_PROCESS", "No automatic dose default; product/concentration can default after verification", "Product, concentration, dose calculation, infusion rate, start/stop, lot/expiry if clinic requires", "Search DPD; confirm controlled-drug storage/logging, pump protocol, rescue plan", "https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/drug-product-database.html", "Dose/rate should remain encounter-specific and physician-reviewed."], ["INFUSION_PUMP", "Medical device/equipment", "Infusion pump", "Programmable infusion pump", "Infusion device", "Model-specific", "Ketamine and other infusions", "infusion_pump;infusion_rate;monitoring", "Health Canada MDALL", "VERIFY_ACTIVE_DEVICE_AND_MAINTENANCE", "Global default for pump model after verification", "Pump model, program/rate, monitoring, start/stop times", "Search MDALL and maintain pump service record", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Infusion rate remains encounter-specific."], ["MONITORING_EQUIPMENT", "Medical device/equipment", "Monitoring", "NIBP/pulse oximetry/capnography as applicable", "Patient monitoring devices", "Device/model-specific", "RFA/infusion/procedure monitoring", "monitoring;vital_signs;sedation_score", "Health Canada MDALL / clinic equipment log", "VERIFY_EQUIPMENT_AND_PROTOCOL", "Global monitoring phrase default allowed", "Monitoring modality, vitals, adverse events", "Verify equipment availability/service and clinic protocol", "https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/licences/medical-devices-active-licence-listing.html", "Use clinic protocol wording; don't default actual vitals."], ["STERILE_PREP_CHG", "Medication/Solution", "Skin antiseptic", "Chlorhexidine skin prep", "Chlorhexidine", "Product-specific formulation", "All sterile procedures", "skin_prep", "Health Canada product label / DPD where applicable", "VERIFY_PRODUCT_AND_ALLERGY", "Global default allowed with allergy override", "Prep agent and allergy/contraindication if applicable", "Verify product label and clinic infection prevention policy", "https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/drug-product-database.html", "Alternatives should be listed for CHG allergy."], ["STERILE_PREP_POVIDONE", "Medication/Solution", "Skin antiseptic alternative", "Povidone-iodine skin prep", "Povidone-iodine", "Product-specific formulation", "Alternative sterile prep", "skin_prep", "Health Canada product label / DPD where applicable", "VERIFY_PRODUCT_AND_ALLERGY", "Alternative global option", "Prep agent and allergy/contraindication if applicable", "Verify product label and clinic infection prevention policy", "https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/drug-product-database.html", "For CHG allergy or site-specific requirements."]], "product_default_profiles": [["GLOBAL_INJECTION_BASE", "Global", "skin_prep", "Chlorhexidine skin preparation; allow to dry completely before needle entry. Use alternative if allergy/contraindication.", "Global Default", "YES", "VERIFY_PRODUCT_AND_ALLERGY", "Product choice only; actual allergy response is manual."], ["GLOBAL_INJECTION_BASE", "Global", "sterile_setup", "Sterile gloves, sterile gel, sterile probe cover when ultrasound-guided, sterile drape as appropriate.", "Global Default", "YES", "VERIFY_CLINIC_PROTOCOL", "Uses clinic protocol language."], ["GLOBAL_US_BASE", "Global", "ultrasound_machine", "[set verified clinic ultrasound machine/model]", "Global Default", "YES_AFTER_MDALL", "VERIFY_ACTIVE_DEVICE_AND_MAINTENANCE", "Leave blank until model is verified."], ["JOINT_STEROID_BASE", "Joint steroid injection", "injectate_product", "Triamcinolone acetonide or methylprednisolone acetate - verify exact product/DIN", "Per-Form Default", "YES_AFTER_DPD", "VERIFY_ACTIVE_DPD_DIN", "Procedure-specific default; exact dose remains physician-reviewed."], ["JOINT_STEROID_BASE", "Joint steroid injection", "diluent_anesthetic", "Lidocaine 1% or preservative-free local anesthetic as selected - verify product/DIN", "Per-Form Default", "YES_AFTER_DPD", "VERIFY_ACTIVE_DPD_DIN", "Exact volume remains editable."], ["SPINE_NONPARTICULATE_OPTION", "Spine/fluoro injection", "injectate_product", "Dexamethasone sodium phosphate - verify exact product/DIN if selected", "Per-Form Default", "YES_AFTER_DPD", "VERIFY_ACTIVE_DPD_DIN", "Option profile; not automatically applied."], ["HA_SINGLE_INJECTION_BASE", "Hyaluronic acid injection", "ha_product", "[select verified HA product: e.g., Durolane/Synvisc-One/Monovisc/Cingal/etc. after MDALL check]", "Per-Form Default", "YES_AFTER_MDALL", "VERIFY_ACTIVE_MDALL_DEVICE", "Keep placeholder until chosen product is stocked/verified."], ["HA_SINGLE_INJECTION_BASE", "Hyaluronic acid injection", "ha_volume", "[enter product-specific labeled volume]", "No Default", "NO_PRODUCT_SPECIFIC_DEFAULT_UNTIL_SELECTED", "VERIFY_ACTIVE_MDALL_DEVICE", "Volume is product-specific and should not default globally."], ["PRP_INTRAARTICULAR_BASE", "PRP", "prp_system", "[select verified PRP kit/system and protocol]", "Per-Form Default", "YES_AFTER_DEVICE_VERIFICATION", "VERIFY_ACTIVE_DEVICE_OR_SUPPLIER", "Kit/system only; actual yield and volume manual."], ["PRP_INTRAARTICULAR_BASE", "PRP", "prp_volume", "", "No Default", "NO", "MANUAL_PATIENT_SPECIFIC", "Actual PRP yield/injected volume must be manual."], ["PROLO_LIGAMENT_BASE", "Prolotherapy", "prolo_solution", "[clinic-approved dextrose/local anesthetic solution; verify product/source]", "Per-Form Default", "YES_AFTER_PROTOCOL", "VERIFY_PRODUCT_OR_COMPOUNDING", "Concentration/volume must be explicit and reviewed."], ["PROLO_LIGAMENT_BASE", "Prolotherapy", "dextrose_concentration", "", "No Default", "NO", "MANUAL_OR_PROTOCOL_SELECTION", "Concentration can be protocol-selected but should be visible for review."], ["HYDRODISSECTION_MEDIAN_BASE", "Hydrodissection", "hydrodissection_solution", "Preservative-free saline +/- local anesthetic as selected; verify product/DIN/label", "Per-Form Default", "YES_AFTER_DPD", "VERIFY_STOCK_AND_LABEL", "Actual volume/spread manual."], ["RFA_BASE", "Radiofrequency ablation", "rfa_generator", "[set verified RF generator model]", "Global Default", "YES_AFTER_MDALL", "VERIFY_ACTIVE_DEVICE_AND_MAINTENANCE", "Model may default once verified; settings remain visible."], ["RFA_BASE", "Radiofrequency ablation", "rf_cannula", "[set verified RF cannula gauge/length/active tip by form]", "Per-Form Default", "YES_AFTER_DEVICE_VERIFICATION", "VERIFY_DEVICE_AND_STOCK", "Exact lot/expiry manual if tracked."], ["RFA_GENICULAR_BASE", "Genicular RFA", "rf_temperature_c", "80", "Per-Form Default", "YES_PROTOCOL_DEFAULT", "PHYSICIAN_VERIFY_EACH_CASE", "Starter protocol value only, not a locked order."], ["RFA_GENICULAR_BASE", "Genicular RFA", "rf_duration_sec", "90", "Per-Form Default", "YES_PROTOCOL_DEFAULT", "PHYSICIAN_VERIFY_EACH_CASE", "Starter protocol value only."], ["KETAMINE_INFUSION_BASE", "Ketamine infusion", "ketamine_product", "Ketamine injection - verify exact product/DIN/concentration", "Per-Form Default", "YES_AFTER_DPD", "VERIFY_ACTIVE_DPD_DIN_AND_CONTROLLED_DRUG_PROCESS", "Dose/rate must remain encounter-specific."], ["KETAMINE_INFUSION_BASE", "Ketamine infusion", "infusion_pump", "[set verified infusion pump model]", "Global Default", "YES_AFTER_MDALL", "VERIFY_ACTIVE_DEVICE_AND_MAINTENANCE", "Pump model can default after verification."], ["KETAMINE_INFUSION_BASE", "Ketamine infusion", "infusion_rate", "", "No Default", "NO", "MANUAL_PATIENT_SPECIFIC", "Never default actual patient rate."]], "product_field_map_count": 473, "verification_workflow": [["1", "Search Health Canada DPD for medication active ingredient/product", "Steroids, local anesthetics, contrast, ketamine, injectable solutions", "DIN, product name, manufacturer, status, concentration/presentation, monograph/label link", "Before stocking and when supplier/product changes", "Medical Director / delegated clinical lead"], ["2", "Search MDALL / supplier licensing pathway for Class II-IV devices and relevant device families", "HA products, PRP kits if applicable, ultrasound, RF generator/cannula, infusion pumps, monitors", "Licence/device name, licence number if applicable, status, manufacturer, device identifier if needed", "Before stocking, annually, and when model/version changes", "Medical Director / operations lead"], ["3", "Confirm supply-chain documents", "Class I disposables, needles, syringes, sterile prep, PRP kits if not located by device name", "Supplier, MDEL if applicable, IFU/package insert, lot/expiry tracking process", "Before purchase and at reorder review", "Operations lead"], ["4", "Set global defaults only for clinic-wide, low-variance items", "Skin prep, sterile setup phrase, clinic monitoring phrase, machine model", "Default date, reviewer, source, fallback for allergy/contraindication", "At policy review", "Medical Director"], ["5", "Set per-form defaults for procedure-specific technique/product choices", "Knee steroid, HA, PRP, RFA, hydrodissection, prolotherapy, ketamine", "Profile ID, exact form IDs, product IDs, protocol settings, exceptions", "At procedure protocol review", "Medical Director"], ["6", "Keep encounter-specific/no-default fields blank", "Lot/expiry, side, diagnosis, complications, actual spread, stimulation results, dose/rate/yield", "EMR note generated from current encounter only", "Every encounter", "Treating physician"], ["7", "Audit notes and defaults", "All products/forms", "Random chart audit; unresolved placeholders; product status review log", "Quarterly or after incident/supply change", "Medical Director / QA"]]}}</script>
  <script>
    const DATA = JSON.parse(document.getElementById('epione-data').textContent);
    const forms = DATA.forms;
    const conditions = DATA.conditions;
    const globals = DATA.global_defaults || {};
    const productRows = (DATA.product_library && DATA.product_library.product_rows) || [];
    const state = { conditionId: conditions[0]?.condition_id || null, formId: null, type: 'all', query: '', valuesByForm: {}, guidance: '', interventionType: '', procedureGroup: '' };
    const FAVORITE_STORAGE_KEY = 'epione_procedure_favorites_v1';

    const $ = (id) => document.getElementById(id);
    const formById = Object.fromEntries(forms.map(f => [f.form_id, f]));
    const conditionById = Object.fromEntries(conditions.map(c => [c.condition_id, c]));

    function defaultKey(key, form) {
      const context = [form.form_id, form.title, form.family, form.category, form.form_type].join(' ').toLowerCase();
      if (key === 'guidance_phrase') return context.includes('fluoro') || context.includes('fluoroscopy') ? 'fluoroscopy_guidance_phrase' : 'ultrasound_guidance_phrase';
      if (key === 'monitoring') {
        if (context.includes('rfa') || context.includes('radiofrequency')) return 'default_monitoring_rfa';
        if (context.includes('infusion') || context.includes('ketamine')) return 'default_monitoring_infusion';
        return 'default_monitoring_injection';
      }
      return key;
    }

    function formDefaults(form) { return form.defaults || form.procedure_defaults || {}; }
    function hasValue(v) { return v !== undefined && v !== null && String(v).trim() !== ''; }
    function currentValues(form = formById[state.formId] || {}) {
      const id = form.form_id || state.formId || 'unselected';
      return state.valuesByForm[id] ||= {};
    }
    function conditionForms() {
      const condition = conditionById[state.conditionId] || conditions[0];
      if (!condition) return {};
      return {
        condition,
        history: formById[condition.history_form_id],
        exam: formById[condition.exam_form_id],
      };
    }

    function procedureFormsForCurrentCondition() {
      const condition = conditionById[state.conditionId] || conditions[0];
      const ids = condition ? (condition.procedure_ids || []) : [];
      return ids.map(id => formById[id]).filter(Boolean);
    }

    function resolveField(form, field) {
      const key = field.key;
      const entered = currentValues(form)[key];
      if (hasValue(entered)) return { value: String(entered), source: 'Encounter' };
      if (field.default_layer === 'No Default') return { value: '', source: 'Manual only' };
      const per = formDefaults(form)[key];
      if (field.default_layer === 'Per-Form Default' && hasValue(per)) return { value: String(per), source: 'Per-form' };
      const globalValue = globals[defaultKey(key, form)];
      if (field.default_layer === 'Global Default' && hasValue(globalValue)) return { value: String(globalValue), source: 'Global' };
      if (hasValue(per)) return { value: String(per), source: 'Per-form' };
      if (hasValue(globalValue)) return { value: String(globalValue), source: 'Global' };
      return { value: '', source: 'Blank' };
    }

    function selectedForms() {
      const condition = conditionById[state.conditionId] || conditions[0];
      const ids = condition ? [condition.history_form_id, condition.exam_form_id, ...(condition.procedure_ids || [])] : forms.map(f => f.form_id);
      let list = ids.map(id => formById[id]).filter(Boolean);
      if (state.type !== 'all') list = list.filter(f => f.form_type === state.type);
      if (state.type === 'Procedure' || list.every(f => f.form_type === 'Procedure')) {
        list = applyGuideFilters(list);
      }
      if (state.query) {
        const q = state.query.toLowerCase();
        list = forms.filter(f => [f.title, f.form_id, f.family, f.category, f.condition_tags].join(' ').toLowerCase().includes(q));
      }
      return list;
    }

    function applyGuideFilters(list) {
      return list.filter(form => {
        const nav = form.navigator || {};
        const guidance = Array.isArray(nav.guidance_options) ? nav.guidance_options : [];
        if (state.guidance && !guidance.includes(state.guidance)) return false;
        if (state.interventionType && nav.intervention_type !== state.interventionType) return false;
        if (state.procedureGroup && nav.procedure_group !== state.procedureGroup) return false;
        return true;
      });
    }

    function selectForm(formId) {
      state.formId = formId;
      resetReview();
      render();
    }

    function allFavorites() {
      try { return JSON.parse(localStorage.getItem(FAVORITE_STORAGE_KEY) || '{}'); }
      catch (_) { return {}; }
    }
    function saveAllFavorites(favorites) {
      localStorage.setItem(FAVORITE_STORAGE_KEY, JSON.stringify(favorites));
    }
    function favoritesForForm(formId = state.formId) {
      return allFavorites()[formId] || [];
    }
    function renderFavorites(form) {
      const favorites = favoritesForForm(form.form_id);
      $('favoriteSelect').innerHTML = '<option value="">No saved favorite</option>' + favorites.map((fav, index) => `<option value="${index}">${escapeHtml(fav.name || 'Favorite ' + (index + 1))}</option>`).join('');
      $('favoriteStatus').textContent = favorites.length ? `${favorites.length} saved for this procedure.` : 'Save usual choices for this procedure.';
    }
    function saveFavorite(form) {
      const name = $('favoriteName').value.trim() || `${form.title} favorite`;
      const values = { ...currentValues(form) };
      const nav = form.navigator || {};
      const favorite = {
        name,
        savedAt: new Date().toISOString(),
        formId: form.form_id,
        conditionId: state.conditionId,
        navigator: {
          guidance: state.guidance || (nav.guidance_options || [])[0] || '',
          interventionType: state.interventionType || nav.intervention_type || '',
          procedureGroup: state.procedureGroup || nav.procedure_group || '',
        },
        values,
      };
      const all = allFavorites();
      const list = all[form.form_id] || [];
      list.push(favorite);
      all[form.form_id] = list;
      saveAllFavorites(all);
      $('favoriteName').value = '';
      renderFavorites(form);
      $('favoriteSelect').value = String(list.length - 1);
      $('favoriteStatus').textContent = 'Saved favorite for this procedure.';
    }
    function applyFavorite(form) {
      const index = Number($('favoriteSelect').value);
      const favorite = favoritesForForm(form.form_id)[index];
      if (!favorite) return;
      state.valuesByForm[form.form_id] = { ...(favorite.values || {}) };
      if (favorite.navigator) {
        state.guidance = favorite.navigator.guidance || state.guidance;
        state.interventionType = favorite.navigator.interventionType || state.interventionType;
        state.procedureGroup = favorite.navigator.procedureGroup || state.procedureGroup;
      }
      $('favoriteStatus').textContent = 'Applied favorite.';
      render();
    }
    function deleteFavorite(form) {
      const index = Number($('favoriteSelect').value);
      if (Number.isNaN(index)) return;
      const all = allFavorites();
      const list = all[form.form_id] || [];
      if (!list[index]) return;
      list.splice(index, 1);
      all[form.form_id] = list;
      saveAllFavorites(all);
      renderFavorites(form);
      $('favoriteStatus').textContent = 'Deleted favorite.';
    }

    function renderConditions() {
      $('conditions').innerHTML = conditions.map(c => `
        <button class="row-button ${c.condition_id === state.conditionId ? 'active' : ''}" data-condition="${c.condition_id}">
          <div class="row-title">${escapeHtml(c.condition)}</div>
          <div class="row-meta">${(c.procedure_ids || []).length} procedures</div>
        </button>
      `).join('');
      $('conditions').querySelectorAll('button').forEach(btn => btn.addEventListener('click', () => {
        state.conditionId = btn.dataset.condition;
        state.query = '';
        state.guidance = '';
        state.interventionType = '';
        state.procedureGroup = '';
        $('search').value = '';
        state.formId = null;
        state.type = 'Procedure';
        $('typeTabs').querySelectorAll('button').forEach(b => b.classList.toggle('active', b.dataset.type === 'Procedure'));
        render();
      }));
    }

    function renderGuidedPath() {
      const base = procedureFormsForCurrentCondition();
      const afterGuidance = state.guidance ? base.filter(f => ((f.navigator || {}).guidance_options || []).includes(state.guidance)) : base;
      const afterIntervention = state.interventionType ? afterGuidance.filter(f => (f.navigator || {}).intervention_type === state.interventionType) : afterGuidance;
      const steps = [
        { key: 'guidance', label: 'Guidance technique', value: state.guidance, options: countedOptions(base, f => (f.navigator || {}).guidance_options || []) },
        { key: 'interventionType', label: 'Intervention type', value: state.interventionType, options: countedOptions(afterGuidance, f => [(f.navigator || {}).intervention_type || 'Procedure']) },
        { key: 'procedureGroup', label: 'Procedure family', value: state.procedureGroup, options: countedOptions(afterIntervention, f => [(f.navigator || {}).procedure_group || f.family || 'Procedure']) },
      ];
      $('guidedPath').innerHTML = steps.map(step => guideStepHtml(step)).join('');
      $('guidedPath').querySelectorAll('[data-guide-key]').forEach(btn => btn.addEventListener('click', () => {
        const key = btn.dataset.guideKey;
        const value = btn.dataset.guideValue || '';
        state[key] = state[key] === value ? '' : value;
        if (key === 'guidance') { state.interventionType = ''; state.procedureGroup = ''; }
        if (key === 'interventionType') state.procedureGroup = '';
        state.formId = null;
        state.type = 'Procedure';
        $('typeTabs').querySelectorAll('button').forEach(b => b.classList.toggle('active', b.dataset.type === 'Procedure'));
        render();
      }));
      $('guidedPath').querySelectorAll('[data-clear-guide]').forEach(btn => btn.addEventListener('click', () => {
        const key = btn.dataset.clearGuide;
        state[key] = '';
        if (key === 'guidance') { state.interventionType = ''; state.procedureGroup = ''; }
        if (key === 'interventionType') state.procedureGroup = '';
        state.formId = null;
        render();
      }));
    }

    function guideStepHtml(step) {
      const selected = step.value ? `<button class="choice-button active" data-guide-key="${step.key}" data-guide-value="${escapeAttr(step.value)}">${escapeHtml(step.value)}<span class="count">selected</span></button>` : '';
      const options = step.value ? selected : step.options.map(([value, count]) => `
        <button class="choice-button" data-guide-key="${step.key}" data-guide-value="${escapeAttr(value)}">${escapeHtml(value)}<span class="count">${count}</span></button>
      `).join('');
      return `
        <div class="guide-step">
          <button class="guide-question" data-clear-guide="${step.key}" type="button">${escapeHtml(step.label)}<span>${step.value ? 'Click to change' : 'Choose one'}</span></button>
          <div class="choice-grid">${options || '<div class="empty">No options for this condition.</div>'}</div>
        </div>`;
    }

    function countedOptions(list, getter) {
      const counts = {};
      list.forEach(item => getter(item).filter(Boolean).forEach(value => counts[value] = (counts[value] || 0) + 1));
      return Object.entries(counts).sort((a, b) => b[1] - a[1] || a[0].localeCompare(b[0]));
    }

    function renderFormPicker(list) {
      if (!state.formId && list.length) state.formId = list[0].form_id;
      $('formList').innerHTML = list.length ? list.map(f => `
        <button class="row-button ${f.form_id === state.formId ? 'active' : ''}" data-form="${f.form_id}">
          <div class="row-title">${escapeHtml(f.title)}</div>
          <div class="row-meta">${escapeHtml(f.form_type || '')} · ${escapeHtml(f.family || f.category || '')}</div>
        </button>`).join('') : '<div class="empty">No matching forms for this condition and type.</div>';
      $('formList').querySelectorAll('button').forEach(btn => btn.addEventListener('click', () => selectForm(btn.dataset.form)));
    }

    function renderFields(form) {
      const groups = groupBy(form.fields || [], f => f.section || 'Other');
      $('fields').innerHTML = Object.entries(groups).map(([section, fields]) => `
        <div class="field-group">
          <div class="group-title">${escapeHtml(section)}</div>
          ${fields.map(field => fieldHtml(form, field)).join('')}
        </div>
      `).join('');
      $('fields').querySelectorAll('[data-key]').forEach(control => control.addEventListener('input', () => {
        currentValues(form)[control.dataset.key] = control.value;
        renderPreview(form);
      }));
      $('fields').querySelectorAll('[data-preset-for]').forEach(control => control.addEventListener('click', () => {
        if (!control.dataset.presetText) return;
        insertPreset(form, control.dataset.presetFor, control.dataset.presetText);
      }));
    }

    function fieldHtml(form, field) {
      const resolved = resolveField(form, field);
      const values = currentValues(form);
      const fieldOptions = String(field.options || '').split(';').map(s => s.trim()).filter(Boolean);
      const quickOptions = Array.isArray(field.quick_options) ? field.quick_options : String(field.quick_options || '').split(';').map(s => s.trim()).filter(Boolean);
      const presetOptions = [...fieldOptions, ...quickOptions].filter((v, i, arr) => v && arr.indexOf(v) === i);
      const preset = presetOptions.length && field.input_type !== 'select'
        ? `<div class="quick-choice-list" aria-label="Quick text choices for ${escapeAttr(field.label || field.key)}">${presetOptions.map(o => `<button type="button" class="quick-choice compact" title="${escapeAttr(o)}" data-preset-for="${field.key}" data-preset-text="${escapeAttr(o)}">${escapeHtml(o)}</button>`).join('')}</div>`
        : '';
      const control = field.input_type === 'select'
        ? `<select data-key="${field.key}"><option value="">${resolved.value ? 'Use default: ' + escapeHtml(resolved.value) : 'Select'}</option>${fieldOptions.map(o => `<option ${values[field.key] === o ? 'selected' : ''}>${escapeHtml(o)}</option>`).join('')}</select>`
        : field.input_type === 'textarea'
          ? `${preset}<textarea data-key="${field.key}" placeholder="${escapeAttr(resolved.value)}">${escapeHtml(values[field.key] || '')}</textarea>`
          : `${preset}<input data-key="${field.key}" value="${escapeAttr(values[field.key] || '')}" placeholder="${escapeAttr(resolved.value)}">`;
      const contextTag = Array.isArray(field.context_sources) && field.context_sources.length ? '<span class="tag default">Can pull Hx/Exam</span>' : '';
      return `
        <div class="field">
          <div>
            <label>${escapeHtml(field.label || field.key)}</label>
            <div class="help">${escapeHtml(field.help || '')}</div>
            <div class="field-meta">
              <span class="tag ${field.required ? 'required' : ''}">${field.required ? 'Required' : 'Optional'}</span>
              <span class="tag ${field.default_layer === 'No Default' ? 'manual' : 'default'}">${escapeHtml(field.default_layer || '')}</span>
              <span class="tag">${escapeHtml(resolved.source)}</span>
              ${contextTag}
            </div>
          </div>
          <div class="field-controls">${control}</div>
        </div>`;
    }

    function insertPreset(form, key, text) {
      const values = currentValues(form);
      const existing = String(values[key] || '').trim();
      values[key] = existing ? existing + '\n' + text : text;
      render();
    }

    function renderPreview(form) {
      const resolved = Object.fromEntries((form.fields || []).map(field => [field.key, resolveField(form, field)]));
      const missing = (form.fields || []).filter(field => field.required && !hasValue(resolved[field.key].value));
      const defaultCount = Object.values(resolved).filter(v => v.source === 'Per-form' || v.source === 'Global').length;
      const tokenPattern = new RegExp('\\{\\{([^}]+)\\}\\}', 'g');
      let note = String(form.narrative_template || form.template || '').replace(tokenPattern, (_, raw) => {
        const key = raw.trim();
        const value = resolved[key]?.value;
        return hasValue(value) ? value : '[' + key + ']';
      });
      if (missing.length) note += '\n\nMISSING REQUIRED FIELDS: ' + missing.map(f => f.key).join(', ');
      $('note').textContent = note;
      $('missing').innerHTML = missing.length ? missing.map(f => `<div class="missing-item">${escapeHtml(f.label || f.key)}</div>`).join('') : '<div class="tag">No missing required fields</div>';
      $('metricRequired').textContent = (form.fields || []).filter(f => f.required).length;
      $('metricMissing').textContent = missing.length;
      $('metricDefaults').textContent = defaultCount;
      renderProducts(form);
      updateReviewStatus();
    }

    function renderProducts(form) {
      const keys = new Set((form.fields || []).map(f => f.key));
      const rows = productRows.filter(r => String(r[7] || '').split(';').some(k => keys.has(k.trim()))).slice(0, 8);
      $('products').innerHTML = '<div class="panel-head"><h3>Product Verification</h3><span class="pill-no">No approved defaults</span></div>' +
        (rows.length ? rows.map(r => `<div class="product-row"><div><strong>${escapeHtml(r[0])}</strong><br><span>${escapeHtml(r[3])}</span></div><span>${escapeHtml(r[9])}</span></div>`).join('') : '<div class="empty">No mapped product rows for this form.</div>');
    }

    function render() {
      renderConditions();
      renderGuidedPath();
      const list = selectedForms();
      renderFormPicker(list);
      $('metricForms').textContent = list.length;
      const form = formById[state.formId] || list[0];
      if (!form) {
        $('formTitle').textContent = 'No form selected';
        $('fields').innerHTML = '<div class="empty">No matching forms.</div>';
        $('note').textContent = '';
        return;
      }
      state.formId = form.form_id;
      $('formTitle').textContent = form.title;
      $('formMeta').textContent = [form.form_type, form.family || form.category, form.form_id].filter(Boolean).join(' · ');
      renderContextAssist(form);
      renderFavorites(form);
      renderFields(form);
      renderPreview(form);
    }

    function renderContextAssist(form) {
      const { history, exam } = conditionForms();
      const historyValues = history ? currentValues(history) : {};
      const examValues = exam ? currentValues(exam) : {};
      const summaryItems = [
        ['Condition focus', firstValue([historyValues.condition_focus, examValues.condition_focus])],
        ['History impression', historyValues.history_impression_plan],
        ['Pain generator', examValues.pain_generator_impression],
        ['Target assessment', examValues.procedural_target_assessment],
      ];
      $('contextSummary').innerHTML = summaryItems.map(([label, value]) => `
        <div class="context-item"><strong>${escapeHtml(label)}</strong><span>${escapeHtml(shortValue(value))}</span></div>
      `).join('');

      const canPull = form.form_type === 'Procedure' && (form.fields || []).some(field => Array.isArray(field.context_sources) && field.context_sources.length);
      const hxButton = history ? `<button class="btn" data-open-form="${history.form_id}">Open History</button>` : '';
      const examButton = exam ? `<button class="btn" data-open-form="${exam.form_id}">Open Physical Exam</button>` : '';
      $('contextActions').innerHTML = [
        hxButton,
        examButton,
        canPull ? '<button class="btn primary" id="pullContext">Pull Hx/Exam Into Procedure</button>' : '',
      ].join('');
      $('contextStatus').textContent = canPull ? 'Procedure fields can reuse entered history and exam details.' : 'Enter history and exam details here; procedure forms can reuse them.';
      $('contextActions').querySelectorAll('[data-open-form]').forEach(btn => btn.addEventListener('click', () => selectForm(btn.dataset.openForm)));
      const pull = $('pullContext');
      if (pull) pull.addEventListener('click', () => {
        const count = applyContextToProcedure(form);
        $('saveStatus').textContent = count ? `Pulled ${count} fields from history/exam.` : 'No entered history/exam details available to pull.';
        setTimeout(() => $('saveStatus').textContent = 'No patient data leaves this browser.', 2400);
        render();
      });
    }

    function applyContextToProcedure(form) {
      const { history, exam } = conditionForms();
      const sourceValues = { ...(history ? currentValues(history) : {}), ...(exam ? currentValues(exam) : {}) };
      const values = currentValues(form);
      let count = 0;
      (form.fields || []).forEach(field => {
        const sources = Array.isArray(field.context_sources) ? field.context_sources : [];
        if (!sources.length || hasValue(values[field.key])) return;
        const pulled = sources
          .map(key => [key, sourceValues[key]])
          .filter(([, value]) => hasValue(value))
          .map(([key, value]) => `${labelForContextKey(key)}: ${value}`);
        if (pulled.length) {
          values[field.key] = pulled.join('\n');
          count += 1;
        }
      });
      return count;
    }

    function firstValue(values) { return values.find(hasValue) || ''; }
    function shortValue(value) {
      if (!hasValue(value)) return 'Not entered yet';
      const text = String(value).replace(/\s+/g, ' ').trim();
      return text.length > 150 ? text.slice(0, 147) + '...' : text;
    }
    function labelForContextKey(key) {
      const labels = {
        condition_focus: 'Condition',
        pain_generator_impression: 'Pain generator impression',
        history_impression_plan: 'History impression/plan',
        presenting_complaint: 'Presenting complaint',
        pain_location_distribution: 'Pain location/distribution',
        functional_limitations: 'Functional limitation/goals',
        prior_treatments: 'Prior treatments/response',
        imaging_labs_tests: 'Imaging/tests reviewed',
        procedural_target_assessment: 'Procedure target assessment',
        red_flags_neuro_screen: 'History safety screen',
        red_flag_exam_findings: 'Exam red flags',
        current_medications: 'Current medications',
        condition_specific_exam: 'Condition-specific exam',
        exam_plan: 'Exam plan',
        patient_preferences_affordability: 'Patient preference/affordability',
      };
      return labels[key] || key;
    }

    function currentReviewItems() {
      return Array.from(document.querySelectorAll('[data-review]'));
    }

    function resetReview() {
      currentReviewItems().forEach(item => item.checked = false);
      $('reviewNotes').value = '';
      updateReviewStatus();
    }

    function updateReviewStatus() {
      const boxes = currentReviewItems();
      const allChecked = boxes.length > 0 && boxes.every(item => item.checked);
      const missingCount = Number($('metricMissing').textContent || '0');
      const ready = allChecked && missingCount === 0;
      $('reviewStatus').textContent = ready ? 'Ready for EMR' : 'Needs review';
      $('reviewStatus').classList.toggle('ready', ready);
      $('reviewStatus').classList.toggle('blocked', !ready);
      return ready;
    }

    function reviewPacket() {
      const form = formById[state.formId] || {};
      const checks = currentReviewItems().map(item => `${item.checked ? '[x]' : '[ ]'} ${item.nextElementSibling?.textContent || item.dataset.review}`).join('\n');
      return [
        'Epione physician review packet',
        'Form: ' + (form.title || ''),
        'Form ID: ' + (form.form_id || ''),
        'Status: ' + $('reviewStatus').textContent,
        'Reviewer: ' + $('reviewerName').value,
        'Review date: ' + $('reviewDate').value,
        '',
        'Checklist:',
        checks,
        '',
        'Review notes:',
        $('reviewNotes').value || '[none]',
        '',
        'Narrative note:',
        $('note').textContent,
      ].join('\n');
    }

    function groupBy(items, getKey) {
      return items.reduce((acc, item) => { const key = getKey(item); (acc[key] ||= []).push(item); return acc; }, {});
    }
    function escapeHtml(value) { return String(value ?? '').replace(/[&<>"']/g, c => ({'&':'&amp;','<':'&lt;','>':'&gt;','"':'&quot;',"'":'&#39;'}[c])); }
    function escapeAttr(value) { return escapeHtml(value).replace(/\n/g, ' '); }

    $('search').addEventListener('input', e => { state.query = e.target.value.trim(); state.formId = null; render(); });
    $('typeTabs').querySelectorAll('button').forEach(btn => btn.addEventListener('click', () => {
      state.type = btn.dataset.type;
      $('typeTabs').querySelectorAll('button').forEach(b => b.classList.toggle('active', b === btn));
      state.formId = null;
      render();
    }));
    $('copyNote').addEventListener('click', async () => {
      await navigator.clipboard.writeText($('note').textContent);
      $('saveStatus').textContent = 'Copied note to clipboard.';
      setTimeout(() => $('saveStatus').textContent = 'No patient data leaves this browser.', 2200);
    });
    $('exportTxt').addEventListener('click', () => {
      const blob = new Blob([$('note').textContent], { type: 'text/plain' });
      const url = URL.createObjectURL(blob);
      const a = document.createElement('a');
      a.href = url; a.download = `${state.formId || 'epione'}_note.txt`; a.click();
      URL.revokeObjectURL(url);
    });
    currentReviewItems().forEach(item => item.addEventListener('change', updateReviewStatus));
    $('reviewerName').addEventListener('input', updateReviewStatus);
    $('reviewDate').addEventListener('input', updateReviewStatus);
    $('reviewNotes').addEventListener('input', updateReviewStatus);
    $('copyReviewPacket').addEventListener('click', async () => {
      await navigator.clipboard.writeText(reviewPacket());
      $('saveStatus').textContent = 'Copied review packet to clipboard.';
      setTimeout(() => $('saveStatus').textContent = 'No patient data leaves this browser.', 2200);
    });
    $('exportReviewPacket').addEventListener('click', () => {
      const blob = new Blob([reviewPacket()], { type: 'text/plain' });
      const url = URL.createObjectURL(blob);
      const a = document.createElement('a');
      a.href = url; a.download = `${state.formId || 'epione'}_review_packet.txt`; a.click();
      URL.revokeObjectURL(url);
    });
    $('clearInputs').addEventListener('click', () => {
      const form = formById[state.formId];
      if (form) state.valuesByForm[form.form_id] = {};
      render();
    });
    $('saveFavorite').addEventListener('click', () => { const form = formById[state.formId]; if (form) saveFavorite(form); });
    $('applyFavorite').addEventListener('click', () => { const form = formById[state.formId]; if (form) applyFavorite(form); });
    $('deleteFavorite').addEventListener('click', () => { const form = formById[state.formId]; if (form) deleteFavorite(form); });
    $('fillDemo').addEventListener('click', () => {
      const form = formById[state.formId];
      const values = currentValues(form);
      (form.fields || []).forEach(field => { if (field.default_layer === 'No Default') values[field.key] = demoValue(field); });
      render();
    });
    function demoValue(field) {
      const key = field.key;
      if (key.includes('side')) return 'Right';
      if (key.includes('diagnosis')) return 'chronic pain condition under physician review';
      if (key.includes('lot')) return 'Lot/expiry entered at procedure time';
      if (key.includes('complication')) return 'None reported at time of note generation';
      if (key.includes('response')) return 'Immediate response documented after reassessment';
      if (key.includes('image')) return 'Saved to clinic imaging archive';
      return 'Entered encounter-specific detail';
    }
    render();
  </script>
</body>
</html>
