Drain Placement/Exchange Procedure Note

Procedure date and time: [Date and time]

Location: [IR suite / bedside / OR] [Room/Bed]

Patient name and MRN: [Patient name], [MRN]

Primary operator: [Name, credentials]

Referring provider/service: [Name or service]

Target system category: [abscess drain / biliary drain / nephrostomy / pleural drain / other]

Procedure Synopsis

• Procedure performed: [placement / exchange (over-wire) / exchange (tract recanalization) / replacement after dislodgement / upsize / downsize / reposition / drain injection study / removal]
• Target and location: [Target structure, anatomic location, laterality if applicable]
• Approach: [transhepatic / transgluteal / anterior abdominal / posterior / transperitoneal / retroperitoneal / intercostal / other]
• Catheter: [Catheter type] — [French size] — [Locking mechanism if applicable]
• Immediate output: [Volume in mL] — [Appearance] — Specimens sent: [none / culture / Gram stain / cytology / other]
• Securing and configuration: [Securing method] — [Drainage: gravity / bulb suction / wall suction with setting]
• Flush protocol: [Solution] — [Volume] — [Frequency] — Hold for: [pain / leakage / resistance]
• Follow-up plan: [Explicit timing or criteria] — (If not yet arranged, state responsible party for scheduling)

(Limit to 4–8 concise bullets; remove unused lines.)

Indication

[Primary indication, working diagnosis, and for exchanges the reason for revision. Reference pertinent prior imaging with modality, date, and key finding.] (1–3 sentences; do not reinterpret full imaging study.)

Pre-Procedure Evaluation

Coagulation status: [INR, platelets, other relevant labs with date/time]

Anticoagulation management: [Agent(s), last dose, peri-procedural plan] (Include only if applicable.)

Contrast allergy precautions: [None / premedication regimen / contrast avoided with rationale]

Antibiotics: [Agent(s), dose(s), timing relative to procedure] (Or state "Patient already on appropriate coverage.")

Skin prep and sterile technique: [Prep agent] — [Sterile barrier and draping statement]

Informed consent: [Consent statement including who provided consent] (Required—do not leave blank or infer.)

Universal protocol/time-out: [Time-out confirmation statement] (Required—do not leave blank or infer.)

Anesthesia and Sedation

Sedation/anesthesia type: [local only / minimal sedation / moderate sedation / deep sedation (MAC) / general anesthesia]

Sedation provided by: [IR team / Anesthesiology / other]

Local anesthetic: [Agent, concentration, volume, site(s)]

Sedation/analgesic medications: [Drug, dose, route, time for each agent administered]

Monitoring: [Monitoring statement or reference to nursing sedation record]

Moderate Sedation Documentation

(Include this section only if moderate sedation performed by proceduralist team.)

Independent trained observer: [Name, role]

Intraservice sedation time: Start [time], End [time] (or Total minutes: [duration])

Presence attestation: [Attestation that operator was present face-to-face for entirety of intraservice moderate sedation]

Procedure Details

[Patient position] under [ultrasound / fluoroscopy / CT] guidance. Skin entry site: [Site and surface landmarks].

Target: [Anatomic structure and side]. Approach: [Approach description]. (Include rationale if nonstandard.)

Access technique: [Seldinger / trocar] via [over-wire / new tract]. [Guidewire type if relevant]. [Tract dilation method and size if performed].

(For exchanges) Existing catheter condition: [functional / malfunctioning / clogged / dislodged / other]. Contrast injection: [yes / no]; findings: [brief actionable findings]. Exchange method: [over-wire / recanalization / replacement]. Reason for size change: [rationale if applicable].

Catheter placed: [Catheter type] [French size] [Locking mechanism if applicable]. Final position confirmed by: [method].

Secured with: [suture type / securement device] and [dressing type]. Drainage: [gravity / bulb suction / wall suction with setting].

(If drain injection study performed) Findings: [Residual cavity size, communications/fistulae, obstruction, or other actionable findings]. (Limit to management-relevant findings.)

Per-Drain Summary

(For single-drain procedures, incorporate this information into Procedure Details above. For multiple drains, duplicate this block for each drain.)

Drain #[number]

Drain label: [Label matching nursing documentation]

Target location: [Anatomic site and laterality]

Approach and entry site: [Approach] — [Skin entry location]

Catheter type and size: [Type] — [French size] — [Locking mechanism]

Drainage configuration: [gravity bag / bulb suction / wall suction with setting]

Initial output: [Volume in mL] — [Appearance] (If none aspirated, state "No fluid aspirated at time of placement.")

Specimens sent: [None / aerobic culture / anaerobic culture / Gram stain / cytology / other] (List only those actually sent.)

Securing method: [Suture type] — [Securement device] — [Dressing]

Flush protocol: [Solution] — [Volume] — [Frequency] — Hold for: [pain / leakage / resistance]

Contrast, Radiation, and Medications

Contrast: [Type/concentration] — Total volume: [mL] (Through drain: [mL]; IV: [mL]) (Omit if no contrast used.)

Fluoroscopy: Time: [minutes]; Reference air kerma: [mGy]; Kerma–area product: [Gy·cm²] (If ultrasound-only: "No fluoroscopy used.")

Additional medications: [Other agents administered, e.g., tPA instilled, sclerosant, heparinized flushes] (Omit if none.)

Complications and Disposition

Estimated blood loss: [Volume in mL]

Immediate complications: [No immediate complications] (Or describe event, management, and outcome.)

End-of-procedure condition: [Patient status: stable, pain controlled, drain functioning, etc.]

Disposition: [Returned to floor / ICU / discharged home / admitted for observation] — [Non-routine monitoring if any]

Post-Procedure Plan

• Drain care orders: [Flush protocol, dressing change frequency, output recording frequency, bag/suction management]
• Antibiotics: [Agent and duration, or "Per primary team" if managed elsewhere]
• Follow-up imaging: [Tube check / abscessogram / CT / cholangiogram / nephrostogram] in [explicit interval or criteria]
• Follow-up procedure/clinic: [Exchange or removal timing/criteria] (If not arranged, state responsible party.)
• Escalation instructions: Contact [IR / primary team] for [fever, increasing pain, erythema, leakage, bleeding, dislodgement, inability to flush, abrupt output change]

Attestations

[Attestation that operator performed/supervised procedure, reviewed images, and confirmed final catheter position]

[Critical result communication if applicable: findings communicated to recipient, date/time]