Sacroiliac / posterior pelvic ligament prolotherapy

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
Technique	Transducer / probe	`transducer`	Per-Form Default	Optional
Technique	Needle approach	`approach`	Per-Form Default	Required
Technique	Needle target	`target`	Per-Form Default	Required
Technique	Needle type / gauge / length	`needle`	Per-Form Default	Required
Technique	Needle visualization / path	`needle_visualization`	No Default	Required
Technique	Injection character / resistance / spread	`injection_character`	No Default	Required
Injectate/Product	Prolotherapy solution	`injectate_product`	Per-Form Default	Required
Injectate/Product	Concentration and aliquot volumes	`dose_volume`	Per-Form Default	Required
Injectate/Product	Lot number and expiry	`lot_expiry`	No Default	Required
Injectate/Product	Diluent / local anesthetic component	`diluent_anesthetic`	Per-Form Default	Optional
Injectate/Product	Total injectate volume	`total_volume`	Per-Form Default	Required
Technique	Exact sites treated	`sites_treated`	No Default	Required
Technique	Number of needle placements	`number_of_needle_placements`	No Default	Required
Technique	Neurovascular structures identified/avoided	`neurovascular_avoidance`	No Default	Required

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

Technique

Transducer / probe

transducer

Per-Form Default

Optional

Technique

Needle approach

approach

Per-Form Default

Required

Technique

Needle target

target

Per-Form Default

Required

Technique

Needle type / gauge / length

needle

Per-Form Default

Required

Technique

Needle visualization / path

needle_visualization

No Default

Required

Technique

Injection character / resistance / spread

injection_character

No Default

Required

Injectate/Product

Prolotherapy solution

injectate_product

Per-Form Default

Required

Injectate/Product

Concentration and aliquot volumes

dose_volume

Per-Form Default

Required

Injectate/Product

Lot number and expiry

lot_expiry

No Default

Required

Injectate/Product

Diluent / local anesthetic component

diluent_anesthetic

Per-Form Default

Optional

Injectate/Product

Total injectate volume

total_volume

Per-Form Default

Required

Technique

Exact sites treated

sites_treated

No Default

Required

Technique

Number of needle placements

number_of_needle_placements

No Default

Required

Technique

Neurovascular structures identified/avoided

neurovascular_avoidance

No Default

Required

Narrative template

Sacroiliac / posterior pelvic ligament prolotherapy - ultrasound-guided

Indication: {{side}} procedure for {{diagnosis}}. {{clinical_indication}}

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

Setup: The patient was positioned {{patient_position}}. Skin preparation: {{skin_prep}} Sterile setup: {{sterile_setup}} Monitoring: {{monitoring}}

Guidance: {{guidance_phrase}} Images: {{image_saved}}

Technique: 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}}

Product/injectate: {{injectate_product}}; {{dose_volume}}. Diluent/local anesthetic: {{diluent_anesthetic}}. Total volume: {{total_volume}}. Lot/expiry: {{lot_expiry}}.

Sites/count: Sites treated: {{sites_treated}}. Needle placements: {{number_of_needle_placements}}. Neurovascular safety: {{neurovascular_avoidance}}.

Outcome: 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.