Bone Marrow Aspiration/Biopsy Procedure Note

Date/Time: [Procedure date and time]

Operator: [Primary operator name, credentials]

Location: [Procedure setting]

Procedure Summary

Bone marrow [aspiration / core biopsy / aspiration and core biopsy] performed from [anatomic site with laterality] under [anesthesia type]; specimens sent for [testing requested].

Indication

[Clinical indication and pre-procedure diagnosis]. [Rationale for planned ancillary testing if applicable].

Pre-Procedure Assessment

[Pertinent labs reviewed: platelet count, coagulation studies if checked]. [Bleeding risk factors: present/absent and details]. [Anticoagulant/antiplatelet status and periprocedural management plan]. [Relevant allergies, including to anesthetics, antiseptics, adhesives]. (If specific information was unavailable, state "Not available at time of documentation.")

Consent

Informed consent was obtained [written / verbal] per institutional policy. Risks (pain, bleeding, infection, dry tap, need for repeat attempt), benefits, and alternatives were discussed; questions were answered; patient [agreed to proceed / lacked capacity and surrogate consent obtained from surrogate]. (This section must always be completed—never omit or imply.)

Time-Out

Time-out performed immediately prior to the procedure confirming two patient identifiers, correct procedure [aspiration / biopsy / both], correct site and laterality, and allergies reviewed.

Anesthesia

Local anesthesia: [Agent, concentration], total volume [mL], infiltrated to [skin / subcutaneous tissue / periosteum].

Sedation: [None / Level: minimal, moderate, or deep]. [Medications with doses and administration times if sedation used]. [Monitoring modalities used]. [Recovery status and readiness for discharge if applicable]. (If no sedation used, state "Sedation: None.")

Technique

[Patient positioning]. [Exact anatomic site and laterality]. [Skin preparation and antiseptic used]. [Sterile draping].

Aspiration: [Needle type/gauge if documented]. [Cortical entry]. [Aspirate attempt result: success / dry tap]. [Repositioning attempts if needed]. [Approximate aspirate volume obtained]. [First-pull technique used for priority specimens: yes/no].

Core biopsy: [Needle type/gauge if documented]. [Number of cores obtained]. [Adequacy: intactness and length if measured]. [If dry tap occurred, note whether touch imprints or clot sections were prepared from the core].

[Imaging guidance: modality and reason, if applicable]. [Patient tolerance throughout the procedure].

Specimens

Specimens labeled at bedside with two patient identifiers. (This section must always include explicit content.)

• Aspirate smears: [Number of slides] for [morphology / iron stain].
• Aspirate in anticoagulant: [Tube type/preservative] for [flow cytometry / cytogenetics/FISH / molecular studies].
• Core biopsy: [Container/preservative] for [histopathology].
• Touch imprints/clot sections: [If prepared, specify for morphology or ancillary studies].

(If specimen handling followed institutional protocol without operator knowledge of specific tube types, state "Specimens allocated per institutional protocol.")

Hemostasis and Dressing

[Hemostasis method: manual pressure for approximately X minutes; hemostatic agent if used]. [Dressing type applied]. [Final site assessment: bleeding controlled, hematoma present/absent].

Estimated Blood Loss

[Minimal / Approximately X mL].

Complications

[None / Description of complication: event, timing, severity, and interventions performed]. (This section must always be completed—never omit.)

Patient Condition and Disposition

[Immediate post-procedure status: alertness, hemodynamic stability, pain control]. [Disposition: discharged home / returned to inpatient unit / to observation]. [If sedation used, confirm discharge criteria met].

Post-Procedure Plan

[Results communication plan: responsible party, expected timeline, method]. [Anticoagulant/antiplatelet restart timing if applicable]. Post-procedure instructions reviewed with patient.