Chest Tube (Tube Thoracostomy) Procedure Note

Date/Time: [Procedure start date and time]

Location: [ED / ICU / OR / procedure room]

Operator: [Name, role, credentials]

Assistants: [Names and roles] (Omit line if none)

Patient Position: [supine / semi-upright / lateral decubitus]

(Meta: This template supports insertion only, removal only, or both in a single session. Omit non-applicable sections entirely. Required fields that must never be omitted: laterality, consent status, time-out status, device size, depth at skin, drainage system setting, air leak status, and complications statement. If any required field is unavailable, document as "unknown" with brief reason.)

Procedure Summary

[Single-sentence summary including laterality, technique (open/blunt dissection vs Seldinger/guidewire), primary indication, and immediate outcome including drainage setting if tube placed]

Indication

[Primary indication: pneumothorax / hemothorax / pleural effusion / empyema] [Context: trauma / iatrogenic / spontaneous] [Ventilation status if relevant] [Therapeutic goal] (Include pertinent symptoms, exam findings, or risk factors only if clinically relevant to approach)

Pre-Procedure Verification and Consent

[Identity verified with two identifiers.] [Procedure and side/site verified and marked per policy.] [Imaging reviewed: CXR / CT / ultrasound confirming side and pathology] (If imaging not reviewed, document emergent exception with rationale.) [Allergies reviewed.] [Anticoagulation/bleeding risk: relevant findings or acceptable status.]

Consent: [Informed consent obtained from patient / surrogate; risks, benefits, and alternatives discussed / Consent not obtained due to emergent necessity: (reason)]

Time-out: [Performed confirming correct patient, procedure, and side/site / Not performed due to (reason); verbal verification performed]

Preparation

• Sterile prep: [Agent used], sterile draping established
• PPE: [Sterile gloves, gown, mask, eye protection as applicable]
• Monitoring: Pulse oximetry and vital signs [; sedation monitoring in place / separate sedation record referenced] (Include sedation details only if sedation used)
• Site selection: [Ultrasound used for site marking with patient in procedure position / Site based on imaging review / Emergency exception: (rationale)]
• Site selected: [Intercostal space number], [anatomic line (e.g., mid-axillary)] [; rationale if nonstandard site]

Anesthesia and Sedation

[Local anesthetic: medication, concentration, volume or total dose, route] [Additional sedation/analgesia if given: medication(s), dose(s), route(s), timing, and who monitored; reference separate sedation record if moderate/deep sedation; note any adverse sedation events] (If local only: "Local anesthesia only; no additional sedation.")

Insertion Details

(Include this section only if a tube was placed)

[Technique: open/blunt dissection vs Seldinger/guidewire; confirmation of pleural entry by aspiration of air or fluid prior to advancement; number of attempts; difficulties encountered if any]

• Tube type: [Standard chest tube / pigtail catheter]
• Size: [French gauge]
• Laterality and insertion site: [Side], [intercostal space], [anatomic line]
• Depth at skin: [cm marking]; side holes confirmed intrathoracic (if fenestrated tube)
• Fixation: [Suture type and material / device lock]
• Dressing: [Type applied]
• Drainage system: [Water seal / suction at −(level) cmH₂O]

Immediate findings:

• Air release: [Yes / no]
• Initial fluid output: [Volume in mL], [character: serous / sanguineous / purulent / chylous]
• Air leak status: [None / intermittent / continuous]; [at rest / with cough / with positive pressure]
• Tidaling/swinging: [Yes / no]
• Patient tolerance: [Brief note if notable]

Specimens sent: [Culture / cell count / chemistries / cytology] (Omit line if no specimens sent)

Removal Details

(Include this section only if a tube was removed)

Indication for removal: [Resolved pneumothorax / minimal output threshold met / no air leak / therapy complete] [Pre-removal status: approximate 24-hour output, air leak status, current setting (water seal vs suction), duration on water seal if tracked]

Removal technique: [Patient positioning; maneuver to reduce air entry (Valsalva / end-expiration hold / none); steady continuous pull with immediate wound occlusion; pre-existing suture tied for closure if applicable; occlusive dressing applied] [Tube removed intact / concern for integrity: (explanation)]

Post-removal status:

• Patient tolerance and respiratory status: [Brief note]
• Dressing: [Occlusive / dry]
• Post-removal imaging: [CXR obtained / CXR ordered / not indicated: (rationale)]

Complications

Complications: [None apparent / (List each complication with brief management)] (If complication suspected but unconfirmed: "Concern for [complication]" with diagnostic/monitoring plan)

Estimated blood loss: [<5 mL / approximately (value) mL]

Post-Procedure Imaging

[Imaging modality (CXR / CT / ultrasound)], [timing], [findings: tube position, lung re-expansion status, residual pneumothorax or effusion, any new complications] (If results pending: "Post-procedure CXR ordered; results pending at time of note." Add dated/timed addendum when results available.)

Orders and Management Plan

(Include this section only if a chest tube remains in place)

• Drainage setting: [Suction at −(level) cmH₂O / water seal]; [planned transition if applicable]
• Clamping: Do not clamp (If clamping trial ordered, document rationale and supervision plan)
• Nursing monitoring: [Frequency] for output and air leak; maintain drain upright and below insertion site; dressing and site checks [frequency]
• Flushing: [Orders and schedule for small-bore drains / not applicable]
• Analgesia: [Orders]
• Escalation criteria: Contact physician for continuous air leak, sudden cessation of drainage with symptoms, worsening dyspnea, large sanguineous output, dislodgement, or significant subcutaneous emphysema

(If tube removed: include dressing care, monitoring frequency, and return precautions as applicable)

Disposition and Communication

(Include only if relevant) [Patient disposition; consultants notified; patient/family communication] (Document communication especially if emergent consent exception was used)

Signature: [Clinician name, credentials, date, time] (If trainee performed under supervision: include attestation that supervising physician was present for key portions per institutional requirements)