Image-Guided Biopsy/Aspiration Procedure Note

Procedure Date/Time: [Start date and time] to [End date and time]

Location: [Facility name], [Room/Suite]

Primary Operator: [Operator name and credentials]

Patient Identifiers: MRN: [MRN] | DOB: [DOB]

Procedure Type: [ultrasound / CT / fluoroscopy / cone-beam CT / MRI / fusion] guidance; [core needle biopsy / fine needle aspiration / both]

Indication

[Clinical indication and objective] (State the purpose for tissue or fluid sampling—diagnosis, staging, infection workup, molecular testing, or therapeutic aspiration—and include the working diagnosis or clinical question.)

Imaging used for target selection: [Modality and date of prior study used to select target] (If no prior imaging available, state "No prior imaging available.")

Pre-Procedure Assessment

• Pertinent comorbidities: [Relevant conditions affecting procedural risk] (If none, state "None relevant.")
• Anticoagulation/Antiplatelet status: [no anticoagulants / agent(s) with last dose timing / not assessed] (If held or reversed, specify details.)
• Pertinent labs: [Platelet count, INR, other per local protocol with date]
• Corrective actions taken: [held medications / transfusion / reversal agent / none required]
• Relevant allergies: [contrast / lidocaine / chlorhexidine / latex / other with reactions] (If none, state "No known relevant allergies.")
• IV contrast plan: [agent, route, volume, and premedication if applicable] (If no contrast intended, state "No IV contrast planned.")

Informed Consent

Informed consent was obtained from [patient / legal representative with relationship] after discussion of the nature of the procedure, risks (including bleeding, infection, injury to adjacent structures, need for additional procedures), benefits, and alternatives. All questions were answered and the patient/representative agreed to proceed. (If consent not obtained, document reason and surrogate decision-making steps taken. Do not omit this section.)

Time-Out

A procedural time-out was performed immediately prior to puncture confirming: correct patient identity (two identifiers), correct procedure, correct site/side/target, patient position, availability of required equipment and imaging, and specimen labeling plan. (If not performed, document reason. Do not omit this section.)

Sedation and Anesthesia

Sedation level: [local only / minimal / moderate / deep / general] provided by [provider/role]. Local anesthetic: [agent, concentration, total dose, route]. Sedation/analgesia administered: [drug name(s) with dose(s) and route(s)] (If none beyond local, state "No sedation administered beyond local anesthesia.") Prophylactic antibiotics: [agent, dose, route / not given]. (If moderate sedation or deeper, document vitals here or reference separate sedation record. If sedation was planned but not given, state reason. Never infer medication administration from orders.)

Procedure

Target: [anatomic site/organ], [laterality if applicable], [target type: solid lesion / cystic lesion / fluid collection], [size], [relevant characteristics such as solid/necrotic/septated].

Imaging guidance: [ultrasound / CT / fluoroscopy / cone-beam CT / fusion], [real-time / intermittent]. Needle position was confirmed by imaging prior to sampling.

Patient position: [supine / prone / lateral decubitus / other]. Entry site and approach: [skin entry site description], [approach: transhepatic / transpleural / paraspinal / subcostal / other]. Skin preparation: [agent]. Sterile technique: [sterile draping, gloves, probe cover if ultrasound].

Devices: [coaxial / non-coaxial] system; introducer [type and gauge / none]; biopsy/aspiration needle [type, gauge, throw length if applicable]. Number of skin punctures: [number]. (State explicitly; do not infer.)

Aspiration/FNA: (Include if performed.) Number of passes: [number]. Aspirate: [volume], [appearance]. On-site cytology adequacy: [performed with result / not performed]. (State explicitly; do not infer.)

Core biopsy: (Include if performed.) Number of cores obtained: [number]. Core length(s): [lengths if measured]. (State explicitly; do not infer.)

Hemostasis adjuncts: [none / gelfoam plug / tract embolization with material / other].

Specimens

• Specimen [number]:
  • Source: [organ/site], [laterality], [specific location]
  • Type: [core / aspirate / fluid]
  • Container/fixative: [formalin / saline / sterile container / cytology media]
  • Testing: [surgical pathology / cytology / flow cytometry / cultures / AFB / fungal / molecular]

(Repeat specimen entry for each additional container.)

Specimens were labeled at bedside with two patient identifiers per institutional policy. (If any specimen obtained but not sent, document which specimen and reason.)

Outcome and Complications

Technical outcome: [successful / partially successful / aborted with reason]. Hemostasis: [method], [status]. Immediate complications: [None / describe]. Estimated blood loss: [Minimal / mL]. Post-procedure imaging check: [modality and findings] (Include when clinically indicated, e.g., chest X-ray after lung biopsy to assess for pneumothorax.)

Radiation and Contrast

(Include this section when CT or fluoroscopy was used. May omit for ultrasound-only procedures.)

• CT dose: CTDIvol [mGy]; DLP [mGy·cm]
• Fluoroscopy: Time [minutes]; Air kerma [mGy]; DAP [Gy·cm²]
• Contrast: [agent, route, volume] (If none, state "No IV contrast administered.")

Disposition and Recovery

Patient tolerated the procedure [well / with issues: describe]. Recovery: [location], [monitoring plan and duration]. Activity restrictions: [bedrest duration / other restrictions]. Pain management: [plan]. Anticoagulation resumption: [timing per protocol / handoff to ordering team for decision].

Follow-Up Plan

• Pending tests: [pathology / cytology / cultures / flow cytometry / molecular]
• Responsible for results: [provider/service and contact method]
• Expected timeframe: [if known]
• If nondiagnostic: [repeat biopsy / alternative imaging / referral / other plan]