Liver Biopsy Procedure Note (Percutaneous)

Date/Time of Procedure: [Date and time]

Location: [Procedure suite / bedside / interventional radiology]

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Primary Operator: [Operator name and credentials]

Procedure Summary

Percutaneous liver biopsy performed under [ultrasound / CT / no image] guidance targeting [non-lesional hepatic parenchyma / focal liver lesion at specified segment]. [Needle type] [gauge]-gauge needle used [with / without] coaxial technique. [Number] passes yielding [number] cores; core length [measured length / not measured]. [Local anesthesia only / moderate sedation] used. Estimated blood loss: [volume in mL / minimal]. Immediate complications: [none / description of complication].

Indication

[Primary indication for biopsy]. Clinical question for pathology: [specific question, e.g., stage fibrosis, rule out autoimmune hepatitis, characterize lesion]. (Include only context that affects risk or approach.)

Pre-Procedure Safety Review

Consent: Informed consent obtained after discussion of risks, benefits, and alternatives. (Note surrogate decision-maker, interpreter, or research tissue collection only if applicable.)

Time-Out: Time-out performed immediately prior to puncture confirming correct patient, procedure, and site.

Bleeding Risk Assessment:

• Platelet count: [value] ([date])
• INR: [value] ([date])
• Anticoagulant/antiplatelet medications: [none / agent(s) with last dose and hold status]
• Bleeding history: [none / relevant details]
• Corrective actions: [none / vitamin K / platelet transfusion / plasma or PCC / route change to transvenous] (Include only if applicable.)
• Decision rationale: [Justification if proceeding with borderline parameters or unavailable labs]

Imaging Review: [Modality and date] reviewed confirming safe access path. Ascites: [absent / present with relevance to approach]. Planned trajectory: [right lobe intercostal / left lobe subxiphoid / other].

Antibiotic Prophylaxis: [Agent, dose, timing] (Include only if given.)

Procedure Details

Positioning and Monitoring: Patient positioned [supine / left lateral decubitus / other]. Monitoring: [BP, pulse oximetry, ECG]. (If sedation beyond local anesthesia: include sedation type/agents, provider, pre-sedation assessment with NPO status and ASA class, monitoring modalities, and designated sedation monitor.)

Sterile Technique: Skin prepped with [prep agent] and sterilely draped; sterile technique maintained throughout.

Local Anesthesia: [Agent and concentration], [volume] mL infiltrated to skin, subcutaneous tissues, and liver capsule.

Guidance and Targeting: [Real-time ultrasound / CT / none] guidance. Target: [non-lesional parenchyma / focal lesion at location/segment]. [Breath-hold instructions given / not applicable].

Needle and Technique: [Needle type] [gauge]-gauge, [throw length if known]. [Coaxial technique used / not used]. Tract embolization: [none / gelfoam / other]. (Include tract embolization only if performed.)

Sampling: [Number] passes yielding [number] cores. Core length: [measured length / not measured]. (If assessed: Specimen adequacy assessed by [operator gross assessment / on-site pathology]: [adequate / limited / inadequate]. Fragmentation: [present / absent].)

Hemostasis: [Manual pressure duration]. Dressing: [type]. Post-biopsy imaging: [performed with findings / not performed].

Estimated Blood Loss: [Volume in mL / minimal]

Complications: [No immediate complications / Description with timing, severity, and interventions]. (Always document explicitly. If observation ongoing, state: no immediate complications; continued monitoring per protocol.)

Specimen Disposition

• Specimens: [Number] cores
• Container/fixative: [Formalin / RPMI / saline / other]
• Destination: [Surgical pathology / microbiology / other]
• Special studies: [None / copper quantification / iron quantification / microbiology culture / flow cytometry / other]
• Labeling confirmed per protocol

Post-Procedure Plan

Monitoring: [Bedrest/positioning instructions]. Vitals: [frequency and duration]. Site checks: [frequency]. Pain control: [analgesic plan]. Escalation criteria: tachycardia, hypotension, increasing pain, dyspnea, or bleeding.

Discharge Criteria: Hemodynamically stable, no evidence of bleeding, no new or worsening abdominal/shoulder pain or dyspnea. [Responsible adult escort required if sedation used.]

Return Precautions: [Activity restrictions and duration]. [Driving/machinery restrictions]. Wound care: [instructions]. Return for: severe abdominal pain, dizziness/syncope, shortness of breath, fever/chills, site bleeding, melena/hematochezia, or increasing abdominal distension.

Antithrombotic Restart: [Restart plan with timing and responsible service / To be determined by specified service]. (Include only if patient was on anticoagulant or antiplatelet therapy.)

Follow-Up

Pathology results to be followed by [proceduralist / ordering clinician]. [Critical result routing instructions if applicable.]