Kidney Biopsy Procedure Note (Pediatrics)

(Do not infer details. If a required element is not explicitly documented, enter [Not documented]. Use exact numeric counts for passes and cores. Laterality and site must be unambiguous. The Immediate Complications section must always contain either "None observed" or a description.)

Date/Time: [Date and time of procedure start and end] (If end time unavailable, document start time only.)

Location: [PICU bedside / IR suite / OR / other]

Procedure: [Procedure name, including guidance modality if used]

Kidney: [Native / Transplant]

Laterality/Site: [Right / Left], [upper / mid / lower] pole cortex (Use unambiguous anatomical language; for transplant, specify iliac fossa location.)

Primary Proceduralist: [Name and credentials]

Assistants/Team: [Names and roles]

Indication: [One-line clinical indication for biopsy]

Indication and Pre-Procedure Status

• [Expanded indication details relevant to diagnostic aims]
• [Relevant labs: platelets, INR, hemoglobin—state values and timing or "reviewed and acceptable per institutional threshold"; if unavailable, state why and mitigation taken]
• [Blood pressure status and control prior to procedure]
• [Anticoagulant/antiplatelet status: agents, last dose, held status, and restart plan]
• [Relevant allergies: chlorhexidine, latex, local anesthetic, others]
• [Baseline symptoms relevant to complication assessment, if any]
• [Other factors impacting bleeding risk or positioning, if applicable]

Consent

[Consent statement] (Document: who provided consent with relationship to patient; whether patient assent was obtained or reason not obtained; confirmation that purpose, material risks, benefits, and alternatives were discussed. If emergent exception applies, document exception and rationale.)

Time-Out and Verification

[Universal Protocol attestation] (Confirm: two patient identifiers verified; correct procedure and site/laterality confirmed; required imaging and labs available and matched to patient; site marking performed or alternate verification process used; time-out completed immediately prior to procedure start with team members present.)

Anesthesia/Sedation

Sedation type: [General anesthesia / Deep sedation / Moderate sedation / Minimal anxiolysis / Local only]

Local anesthetic: [Agent, concentration, and volume administered] (If none, state "No local anesthetic used.")

Sedation details: [If administered by procedural team: list key medications and doses] / [If provided by anesthesia service: "See anesthesia record"] / [If none: "Local anesthetic only"]

Procedure

[Narrative description including: patient positioning; sterile prep and draping; imaging localization and needle path planning; entry site and approach; any difficulties encountered or "performed without difficulty"]

Imaging Guidance: [Modality]; Doppler used: [Yes / No]; Images saved to PACS: [Yes / No]

Needle: [Device type], [Gauge], [Throw length if relevant]

Passes: [Integer count] (Use exact number.)

Cores Obtained: [Integer count] (Use exact number.)

Gross Adequacy: [Cortical tissue visualized / Not assessed] (Do not report glomerular counts unless directly measured.)

(If procedure aborted or sampling limited, document reason, what was obtained, and whether care team/pathology was notified.)

Specimens

Total Cores Submitted: [Integer]

Destination: [Pathology lab name or send-out]

Studies Requested: [LM / IF / EM / Renal biopsy protocol]

Container/Fixative:

• [Core-to-container mapping with fixative and study designation]

Labeling Verified: [Confirmation that all containers labeled with two patient identifiers plus laterality/site, verified against requisition]

(If tissue insufficient for all studies, document which studies were prioritized and who made the decision.)

Hemostasis and Immediate Assessment

• [Hemostasis method(s): manual compression with duration, tract sealant if used, pressure dressing applied]
• [Estimated blood loss: numeric estimate or "minimal"]
• [Immediate post-procedure imaging: modality and findings, or state if not performed]
• [Patient condition at procedure end: hemodynamic status, pain control, urine appearance if observed]

Immediate Complications

Immediate complications: [None observed] / [Description including complication type, timing (intra-procedure vs recovery), and interventions performed] (This field must never be blank.)

Post-Biopsy Orders and Monitoring

Bedrest: [Strict bedrest duration in hours; when ambulation permitted]

Vital Signs: [Monitoring frequency and duration]

Urine Monitoring: [Visual checks for gross hematuria each void; notify provider for clots or retention]

Labs: [Hemoglobin timing if ordered, or "PRN for symptoms/clinical concern"]

Post-Biopsy Imaging: [Only if symptomatic/concerning] / [Routine per institutional protocol]

Analgesia: [Pain management plan]

Anticoagulant Restart: [Explicit timing and agent(s), or responsible service to direct restart]

Escalation Criteria: [Gross hematuria with clots, urinary retention, hypotension/tachycardia, increasing flank pain, falling hemoglobin, fever]

Disposition: [Admit/observation status, expected duration, discharge criteria]

Discharge Instructions and Activity Restrictions

• [Dressing care instructions]
• [Activity restrictions: quiet activity duration; no heavy lifting/strenuous exercise duration; no contact sports duration]
• [How and when biopsy results will be communicated]
• [Return precautions: persistent/worsening gross hematuria, clots, inability to urinate, severe/increasing flank or abdominal pain, dizziness/syncope, fever, bleeding or expanding bruising at site]

Follow-up and Attestation

Family/Guardian Updated: [Yes / No]

Referring Nephrologist Notified: [Yes / No]

Follow-up Plan: [Appointment or contact plan]

[Operator signature and credentials]

[Supervising/attending attestation, if applicable]