How should I document the procedure for a left shoulder subacromial‑subdeltoid bursitis steroid injection, including patient identification, indication, informed consent, needle size, medication (methylprednisolone acetate and lidocaine), and post‑procedure care?

Documentation for Left Shoulder Subacromial-Subdeltoid Bursitis Steroid Injection

Document the procedure using a structured format that includes patient identification, informed consent, sterile technique, medication details, injection approach, and post-procedure instructions, following EULAR guidelines for intra-articular therapies. 1

Pre-Procedure Documentation

Patient Information & Informed Consent

• Patient must be fully informed of the procedure nature, injectable medication, potential benefits and risks; informed consent should be obtained and documented according to local institutional requirements 1
• Document specific discussion points:
  • Expected benefits (pain relief typically lasting weeks to months)
  • Risks: infection (0.035% or 3 per 7,900 procedures), transient hyperglycemia (especially in diabetics), skin atrophy, post-injection pain flare
  • Alternative treatments discussed
  • Patient questions addressed

Indication & Clinical Assessment

• Diagnosis: Left shoulder subacromial-subdeltoid bursitis
• Document clinical findings supporting diagnosis:
  • Pain location and duration (should be ≤6 months for optimal response)
  • Positive impingement signs
  • Range of motion limitations
  • Failed conservative measures (NSAIDs, physical therapy, activity modification) 2

Special Patient Considerations

• Diabetic patients: Document counseling about transient hyperglycemia risk, particularly days 1-3 post-injection, and need for glucose monitoring 1
• Anticoagulation status: Document that bleeding risk is not high (procedure can proceed on anticoagulation unless high bleeding risk) 1
• Pregnancy status: If applicable, document safety considerations for mother and baby 1

Procedure Documentation

Setting & Preparation

Document that procedure performed in:

• Professional, clean, quiet, private, well-lit room 1
• Patient positioned appropriately on examination table, able to lie flat
• Resuscitation equipment available nearby 1

Sterile Technique

Aseptic technique must always be documented 1:

• Skin preparation: 70% alcohol or chlorhexidine/iodine disinfectant
• Sterile gloves worn
• Sterile draping if used

Medications Used

Document exact formulation per FDA labeling 3:

• Methylprednisolone acetate: 40 mg (0.5 mL of 80 mg/mL suspension) or 20-80 mg based on bursa size
• Lidocaine 1%: 0.5-1 mL for local anesthesia
• Total injection volume: Typically 1 mL total

Note: 20 mg triamcinolone is as effective as 40 mg for subacromial injections, suggesting lower methylprednisolone doses may be adequate 4

Needle & Approach

• Needle size: 20-24 gauge 3
• Approach: Document specific entry point
  • Lateral approach (most common for subacromial space)
  • Anterior approach at rotator interval (alternative)
• Guidance method:
  • Landmark-guided (blind technique is as reliable as ultrasound-guided for subacromial bursa) 5
  • OR ultrasound-guided if used (increases accuracy and reduces procedural pain) 4

Injection Technique Details

Document step-by-step per FDA labeling 3:

1. Area prepared with sterile technique
2. Local anesthetic option offered and patient preference documented 1
3. Needle inserted into subacromial-subdeltoid bursa
4. Aspiration attempted (document if fluid obtained)
5. Medication injected without resistance
6. Needle withdrawn
7. Small sterile dressing applied

Critical: Document that injection was into the bursa, not into tendon substance (injection into tendon substance should be avoided) 3

Post-Procedure Documentation

Immediate Post-Procedure

• Patient tolerated procedure well (or document any complications)
• No immediate adverse reactions observed
• Vital signs stable if monitored

Post-Procedure Instructions Given

Document counseling on 1, 6:

• Activity modification: Avoid overuse of injected shoulder for 24 hours; however, immobilization is discouraged 1
• Expected response: Pain relief may begin within 8-12 hours; maximum benefit typically 1-4 weeks 3
• Warning signs: Return immediately for fever, increasing pain, redness, warmth (signs of infection)
• Diabetic patients: Monitor blood glucose closely days 1-3 post-injection 1
• Follow-up: Schedule reassessment in 2-4 weeks

Re-injection Considerations

Document that future re-injection decisions should consider 1:

• Benefits from this injection
• Interval since injection (typically 1-5+ weeks between injections) 3
• Other treatment options
• Individual patient factors

Common Pitfalls to Avoid

• Failure to document informed consent - This is a Grade D recommendation with 99% agreement 1
• Injecting into rotator cuff tendon rather than bursa - leads to treatment failure 3
• Inadequate diabetic counseling - Grade A recommendation to warn about hyperglycemia 1
• Not documenting sterile technique - Grade C recommendation, essential for medicolegal protection 1
• Omitting post-procedure activity instructions - Grade A recommendation to avoid overuse for 24 hours 1