Injection Procedure Patient Process



PURPOSE: Ensure safe and consistent care of all patients. It is the policy of the Southern Grace Pain & Regenerative Medicine to assess each patient on an individual basis regarding the patient’s physical, emotional, and psychological status.

1) Each patient will be assessed initially by the front desk staff for his/her ability to complete paperwork needed for the facility. If the patient cannot complete any forms because of physical or other disabilities, the family member/driver of the patient will be contacted.
2) The medical assistant will then assess the patient regarding the completion of the procedure paperwork. If there is any question about the accuracy of the form’s completion, the MA will follow up with the physician.
3) The MA will assess the patient regarding his/her physical ability to maneuver in and out of the procedure room.
4) A wheelchair will be used if it is needed.
5) Each patient leaving will be escorted to his or her car ambulatory and released to the driver. A wheelchair will be utilized if sedation has been provided prior to the procedure.
6) It is the policy of Southern Grace Pain & Regenerative Medicine that every patient will have a driver that will remain on the premises during the entire patient process. The rare exception to this rule will be a patient who is brought and picked up by a true medical transport that will assume responsibility for the patient or a patient that receives no sedation and has an exemption order written by the physician to allow for taxi/transportation pick up.


1) The MA will obtain patient history including date of birth, allergies, and medical conditions (especially antibiotics and or blood thinner), any recent infections, procedures or illnesses.
2) All female patients ages 16-55 years old will be ask about reproductive status. Any patient that is beyond 30 days from start of last cycle will receive a urine pregnancy test, unless menopausal x3 years or states post-hysterectomy. Patient has the right to refuse urine pregnancy test with signing of release.
3) Verify current list of medications in chart or list medications including dosage and frequency.
4) Provide patient and/or family with verbal discharge instructions. Assess patient and/or family understanding of these instructions and allow to voice any questions/concerns. Once assessment is complete, have patient/surrogate to sign form and witness signature by staff.
5) Obtain signed informed consent.
6) Assess vital signs (BP, pulse rate), if vital signs are out of the parameters consult the physician.
• BP parameters: Systolic 100-180, Diastolic 60-110
• Pulse parameters: 50-100
7) Record vital signs. If Vital signs are out of parameters ,physician is notified and determines whether to proceed or cancel procedure.
8) Place IV following policy/procedure when necessary


1) Assess vital signs at beginning and end of procedure and record: BP, pulse rate, SaO2
2) Assess vital signs post procedure: BP, pulse rate, SaO2
3) Discharge the patient from the post-procedure recovery when the patient’s vital signs are stable, LOC is 1 and pain level is at or below pre-procedure baseline.
4) Discontinue IV access when applicable.
5) Provide patient and/or family with verbal instructions about post-procedure activities.
6) Provide patient with signed copy of post –procedure instructions and satisfaction survey.
7) Discharge patient to car in the care of a responsible adult.