Kidney Biopsy Pre-Procedure Note (Pediatric)

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Age: [Age in years and months]

Weight (kg): [Weight in kilograms]

Allergies: [List allergies with reactions / No known drug allergies / Unknown - obtain prior to proceeding]

Date/Time of Note: [Date and time]

Anticipated Biopsy Date/Time: [Date and time / Pending]

Author/Service: [Name, credentials / Service]

Procedure Type: [Native kidney / Transplant kidney], percutaneous image-guided

Planned Location: [IR suite / OR / Bedside / Other]

Proceduralist: [Name / Pending]

Sedation/Anesthesia Service: [Anesthesiology / Sedation team / IR moderate sedation / Local only / Pending]

One-Line Clinical Summary

[1–3 sentence summary of working diagnosis or clinical syndrome, indication for biopsy, and key procedural risk considerations] (If diagnosis is uncertain, state the working differential and why biopsy is being pursued. Do not infer diagnoses not documented.)

Indication & Clinical Question

Primary Indication: [Steroid-resistant nephrotic syndrome / Persistent hematuria-proteinuria / AKI of unclear etiology / Transplant dysfunction / Other]

Clinical Question(s): [Specific diagnostic or treatment questions the biopsy is intended to answer]

Rationale for Timing: [Change in kidney function / Treatment implications / Failure of empiric therapy / Persistent abnormalities / Other]

Alternatives Considered: [Observation / Empiric therapy / Noninvasive testing / Other] and why inadequate: [Brief rationale]

Pertinent History

• Baseline Kidney Function: [Trend and most recent creatinine/eGFR with dates]
• Prior Kidney Biopsy: [Yes - date, diagnosis, complications / No / Unknown]
• Relevant Systemic Diseases: [SLE / Vasculitis / HUS-TMA / Sickle cell disease or trait / Liver disease / Other / None]
• Transplant-Specific Details: [Time since transplant, donor type, immunosuppression, recent infections or rejection, allograft location] (Omit if native biopsy.)
• Bleeding and Thrombotic History:
  • Source: [Patient report / Parent report / Chart review / Multiple sources]
  • Personal bleeding history: [Findings including easy bruising, prolonged bleeding with procedures, epistaxis, menorrhagia if applicable / None identified / Not assessed] (Do not document "no bleeding history" unless explicitly assessed.)
  • Family bleeding disorders: [Findings / None identified / Unknown]
  • Thrombosis history or anticoagulation indications: [Findings / None / Unknown]
• Current Infection Concerns: [Fever / URI / UTI / Skin infection near puncture site / None / Unknown] (If present, document mitigation or deferral plan.)
• Allergy and Sedation History: [Latex allergy / Prior anesthesia complications - difficult airway, malignant hyperthermia, paradoxical reactions / None / Unknown]

Medication Review

Reconciliation Source: [Parent or patient report / Pharmacy records / Chart review] at [Date and time]

Bleeding-Risk Agents:

• Anticoagulants: [Agent name] - Indication: [Indication]; Last dose: [Date and time / Unknown]; Hold interval: [Duration per protocol]; Restart: [Timing and criteria] / Not taking
• Antiplatelets: [Agent name] - Indication: [Indication]; Last dose: [Date and time / Unknown]; Hold interval: [Duration]; Restart: [Timing] / Not taking
• NSAIDs (including OTC): [Agent name]; Last dose: [Date and time / Unknown]; Hold interval: [Duration]; Restart: [Timing] / Not taking
• Herbals or supplements with bleeding risk: [Agent name]; Last dose: [Date and time / Unknown]; Hold interval: [Duration]; Restart: [Timing] / None reported

(If last dose timing is unknown for any bleeding-risk agent, document that case cannot proceed until clarified. If urgent, document explicit risk-benefit discussion with proceduralist and anesthesia, decision-makers involved, and mitigation plan.)

Pre-Procedure Readiness Assessment

Blood Pressure

• Recent BP readings: [Values with dates and times] in [Inpatient / Clinic] setting
• Antihypertensives taken as scheduled: [Yes / No / Partial / Unknown] (If no, document plan for PRN or IV control.)
• Acceptable for biopsy per protocol: [Yes / No - specify target and optimization plan]

Coagulation Status

• Platelet count: [Value] at [Collection time]
• Hemoglobin/Hematocrit: [Values] at [Collection time]
• PT/INR: [Values] at [Collection time]
• aPTT: [Value] at [Collection time] (If applicable.)
• Interpretation: [Normal / Abnormal - suspected cause and corrective plan: repeat labs, transfusion, DDAVP, hematology consult]
• Minimum hemostasis criteria met: [Yes / No / Pending - specify which result is awaited]

Imaging Review

• Most recent renal imaging: [Ultrasound / CT / MRI] on [Date]
• Findings relevant to access: [Kidney size, cysts, hydronephrosis, masses, malformations, transplant location, solitary kidney status, other pertinent details]
• Imaging adequacy: [Adequate for planning / Inadequate - plan to obtain updated imaging]

Other Considerations

• Active infection: [None / Present - mitigation plan]
• Pregnancy test: [Negative / Positive / Declined per policy / Not applicable / Pending] (For post-menarchal patients per institutional policy.)
• Severe anemia optimization: [Not needed / Needed - plan]
• Blood product availability: [Type and screen / Crossmatched units available / Not indicated / Pending]

Physical Exam

• Vitals: HR [Value], BP [Value], RR [Value], SpO2 [Value], Temp [Value], Pain [Score if relevant] at [Time]
• Cardiopulmonary: [Exam findings]
• Abdomen/Flank: [Tenderness, masses, organomegaly, transplant palpation findings]
• Volume status: [Edema, JVP if assessed, rales, weight trends]
• Airway exam: [Mallampati, mouth opening, neck mobility, craniofacial features] (If this service is responsible for sedation clearance. Otherwise, note known airway risk flags and defer formal assessment to anesthesia.)

Sedation/Anesthesia Plan

• Planned modality: [Local only / Moderate sedation / Deep sedation / General anesthesia]
• Responsible service: [Anesthesiology / Sedation team / IR / Other / Pending]
• ASA physical status: [I / II / III / IV / V / To be assigned by anesthesia]
• NPO status: Solids last at [Time]; Clears last at [Time]; Meets institutional policy: [Yes / No / Unknown] (If not met, document plan to delay or manage.)
• Sedation risk factors: [OSA / Obesity / Craniofacial anomalies / Neuromuscular disease / GERD / None]; Mitigation: [Plan if applicable]
• Planned recovery location: [IR recovery / PACU / Inpatient unit / PICU]
• Anesthesia clearance: [Pending evaluation / Cleared by anesthesia / Not applicable for local-only] (Do not document clearance unless completed by credentialed provider.)

Consent Documentation

• Legal decision-maker: [Name], [Relationship: parent / guardian / other]
• Interpreter: [Yes - language and method / No / Not required]
• Assent: [Obtained / Attempted / Deferred - not developmentally appropriate]; Child's questions or understanding: [Summary if obtained]
• Discussion summary: Nature of procedure; expected benefits; material risks discussed including bleeding, hematoma, hematuria, urinary obstruction, need for transfusion, infection, pain, potential need for embolization or surgery, and anesthesia-related complications; alternatives discussed
• Consent status: [Written consent signed and in chart at location / Pending - procedure cannot proceed]

Procedure Plan

• IV access: [Established / To be placed pre-procedure]
• Labs required prior to transport: [List labs and current status]
• Blood product plan: [Type and screen / Units available / Transfusion thresholds / Not indicated]
• Specimen handling: Pathology notified: [Yes / No / Pending]; Cores required: [Number]; Special studies: [Immunofluorescence / Electron microscopy / Microbiology / Genetic testing / None]
• Transport readiness: [Ready / Pending]; Child life involvement: [Yes / No / Requested]

Post-Procedure Monitoring Plan

• Bedrest: [Duration] in [Position]
• Vital sign frequency: [Schedule per protocol]
• Urine monitoring: Save and inspect all urine; Expected: [Mild hematuria clearing]; Concerning: [Gross hematuria with clots, retention, worsening]
• Pain control: [Analgesia plan and rescue options]
• Post-biopsy CBC: [Time post-procedure]; Recheck threshold: [Hemoglobin drop or value]; Escalation threshold: [Value or change]
• Post-procedure imaging: [Routine ultrasound at time / Symptom-triggered only / Not planned]
• Escalation triggers: Hypotension or tachycardia, increasing pain, gross hematuria with clots or retention, significant hemoglobin drop, expanding hematoma
• Disposition: [Same-day discharge / Overnight observation]; Discharge criteria: [Criteria]
• Activity restrictions: Bedrest [Duration]; Avoid strenuous activity [Duration]; Avoid contact sports and heavy exertion [Duration]
• Return precautions: Gross hematuria, fever, worsening pain, inability to void, dizziness or syncope

(If patient will remain admitted for other reasons, note that discharge instructions will be provided at time of eventual discharge.)

Readiness Attestation

Cleared for biopsy today: [Yes / No / Pending]

[If No or Pending: Missing elements, responsible party, and earliest reassessment time]

[If proceeding despite suboptimal conditions: Risk-benefit discussion summary, decision-makers involved, and mitigation plan]

(When information for any required safety element - bleeding history, last anticoagulant dose, NPO status, or consent - cannot be confirmed, do not mark as cleared. Use "Unknown" or "Pending" with explanation rather than omitting. For elements assessed and found negative or unremarkable, document explicitly.)