Genicular nerve radiofrequency ablation

Form ID: genicular_rfa Type: Procedure Family: Radiofrequency ablation

Structured fields

Section	Field	Key	Default layer	Required
Safety	Consent discussion	`consent_phrase`	Global Default	Required
Safety	Time-out and safety screen	`timeout_phrase`	Global Default	Required
Safety	Allergy / infection / anticoagulant screen result	`allergy_infection_anticoagulant_screen`	No Default	Required
Indication	Diagnosis / indication	`diagnosis`	No Default	Required
Indication	Clinical indication and failed conservative therapy	`clinical_indication`	No Default	Required
Indication	Laterality / side	`side`	No Default	Required
Setup	Patient position	`patient_position`	Per-Form Default	Required
Setup	Skin preparation	`skin_prep`	Global Default	Required
Setup	Sterile setup	`sterile_setup`	Global Default	Required
Setup	Monitoring	`monitoring`	Global Default	Required
Guidance	Guidance modality	`guidance`	Per-Form Default	Required
Guidance	Guidance documentation phrase	`guidance_phrase`	Global Default	Required
Guidance	Images saved / archive location	`image_saved`	No Default	Required
Outcome	Immediate response / pain score change	`immediate_response`	No Default	Required
Outcome	Complications / adverse event	`complications`	No Default	Required
Disposition	Post-procedure instructions	`post_procedure_instructions`	Global Default	Required
Disposition	Follow-up plan	`follow_up_plan`	Global Default	Required
Targets	Levels / nerves targeted	`levels_targets`	No Default	Required
Technique	Imaging modality	`imaging_modality`	Per-Form Default	Required
Technique	RF cannula / active tip	`cannula`	Per-Form Default	Required
Technique	RF generator / technology	`generator`	Per-Form Default	Required
Technique	Electrode orientation / lesion geometry	`electrode_orientation`	Per-Form Default	Required
Stimulation	Sensory stimulation result	`sensory_stimulation`	No Default	Required
Stimulation	Motor stimulation result	`motor_stimulation`	No Default	Required
Lesioning	Lesion temperature/time/settings	`lesion_settings`	Per-Form Default	Required
Lesioning	Number of lesions	`number_of_lesions`	No Default	Required
Lesioning	Post-lesion injectate	`post_lesion_injectate`	Per-Form Default	Optional
Outcome	Post-procedure neurologic status	`post_procedure_neuro_status`	No Default	Required
Targets	Diagnostic block response supporting RFA	`diagnostic_block_response`	No Default	Required
Safety	Anticoagulant/antiplatelet plan	`anticoagulant_hold_details`	No Default	Optional

Section

Field

Key

Default layer

Required

Safety

Consent discussion

consent_phrase

Global Default

Required

Safety

Time-out and safety screen

timeout_phrase

Global Default

Required

Safety

Allergy / infection / anticoagulant screen result

allergy_infection_anticoagulant_screen

No Default

Required

Indication

Diagnosis / indication

diagnosis

No Default

Required

Indication

Clinical indication and failed conservative therapy

clinical_indication

No Default

Required

Indication

Laterality / side

side

No Default

Required

Setup

Patient position

patient_position

Per-Form Default

Required

Setup

Skin preparation

skin_prep

Global Default

Required

Setup

Sterile setup

sterile_setup

Global Default

Required

Setup

Monitoring

monitoring

Global Default

Required

Guidance

Guidance modality

guidance

Per-Form Default

Required

Guidance

Guidance documentation phrase

guidance_phrase

Global Default

Required

Guidance

Images saved / archive location

image_saved

No Default

Required

Outcome

Immediate response / pain score change

immediate_response

No Default

Required

Outcome

Complications / adverse event

complications

No Default

Required

Disposition

Post-procedure instructions

post_procedure_instructions

Global Default

Required

Disposition

Follow-up plan

follow_up_plan

Global Default

Required

Targets

Levels / nerves targeted

levels_targets

No Default

Required

Technique

Imaging modality

imaging_modality

Per-Form Default

Required

Technique

RF cannula / active tip

cannula

Per-Form Default

Required

Technique

RF generator / technology

generator

Per-Form Default

Required

Technique

Electrode orientation / lesion geometry

electrode_orientation

Per-Form Default

Required

Stimulation

Sensory stimulation result

sensory_stimulation

No Default

Required

Stimulation

Motor stimulation result

motor_stimulation

No Default

Required

Lesioning

Lesion temperature/time/settings

lesion_settings

Per-Form Default

Required

Lesioning

Number of lesions

number_of_lesions

No Default

Required

Lesioning

Post-lesion injectate

post_lesion_injectate

Per-Form Default

Optional

Outcome

Post-procedure neurologic status

post_procedure_neuro_status

No Default

Required

Targets

Diagnostic block response supporting RFA

diagnostic_block_response

No Default

Required

Safety

Anticoagulant/antiplatelet plan

anticoagulant_hold_details

No Default

Optional

Narrative template

Genicular Nerve Radiofrequency Ablation

Indication: {{side}} genicular RFA for {{diagnosis}}. Diagnostic block response: {{diagnostic_block_response}}. {{clinical_indication}}

Consent / safety: {{consent_phrase}} {{timeout_phrase}} Safety screen: {{allergy_infection_anticoagulant_screen}}

Setup/guidance: Position: {{patient_position}}. Monitoring: {{monitoring}}. Guidance: {{imaging_modality}}. Images: {{image_saved}}

Targets: {{levels_targets}}. Cannula: {{cannula}}. Generator: {{generator}}. Orientation: {{electrode_orientation}}

Stimulation/lesioning: Sensory stimulation: {{sensory_stimulation}} Motor stimulation: {{motor_stimulation}} Settings: {{lesion_settings}} Number of lesions: {{number_of_lesions}}. Post-lesion injectate: {{post_lesion_injectate}}

Outcome: Neuro status: {{post_procedure_neuro_status}}. Immediate response: {{immediate_response}} Complications: {{complications}}

Disposition: {{post_procedure_instructions}} {{follow_up_plan}}

Physician review required before signing in the EMR. Verify actual medications, doses, lot/expiry, devices, image documentation, response, complications, and follow-up.