Injection: Not type specific Template

Injection: Not type specific Template

💉 Injection: Not type specific Template

❓ Why is this important?

This template provides a standardised framework for documenting injections safely and consistently. It ensures:

  • Patient safety – with risks, consent, and 6 safety checks recorded

  • Consistency – one workflow for all injections, avoiding missed steps

  • Audit and medico-legal protection – comprehensive records of administration

  • Compliance with Local Enhanced Services (LES) – where applicable, a separate section is automatically included at the top of the template to record and code claimable activity

Use this template when giving a routine injection where no condition-specific template is available.

📊 High-level overview of the template structure

The template follows a clear step-by-step process:

  1. Pre-procedure checks – risks, consent, 6 safety checks, cold chain (if relevant)

  2. Administration details – drug, dose, route, site, needle size, technique

  3. Post-procedure documentation – immediate outcome, advice, sharps disposal, Yellow Card if required

📌 What do you need to know?

🧾 Local Enhanced Service (LES) Section

  • Where a Local Enhanced Service exists (e.g. for certain high-value drugs), the LES coding and claim section is automatically shown at the top of the template.

  • Users do not need to find a separate template for LES submissions.

🛠️ Pre-procedure

  • Risks discussed (pain, bleeding, infection, allergic reaction, fainting)

  • Consent obtained and recorded

  • Injection given under PGD or PSD

  • 6 safety checks completed: patient identity, allergies, medicine, dose, route/timing, equipment (anaphylaxis kit ready)

  • Vaccine cold chain confirmed (if relevant)

💉 Administration

  • Route of administration: IM, SC, intradermal, or unspecified injection

  • Specify other injection if not listed

  • Injection site: left/right deltoid, thigh, or other

  • Record needle size if required

  • Injection given as prescribed (with tolerance documented)

✅ Post-procedure

  • Immediate outcome: no reaction, faintness, pain/swelling, allergic reaction

  • Sharps disposed of safely

  • Aftercare advice: monitor for swelling, pain, allergic symptoms, fever; seek help if concerns

  • Suspected adverse reaction → reported via MHRA Yellow Card

💡 Hints and Tips

  • Use this template for all injections without a dedicated template.

  • For B12, Methotrexate, Denosumab, Hormone therapy, or Neuroleptic depot, use the specific templates (these include mandatory extra checks).

  • Always document risks and consent before proceeding.

  • Use recall/future action entries where injections are part of an ongoing course.

👉 See also: