Lumbar Puncture Procedure Note

Date and Time of Procedure: [Date and time of procedure]

Location: [ED / ICU / Ward / Procedure suite]; [Bedside / Imaging-guided (specify modality)]

Primary Proceduralist: [Name, credentials]

Procedure Type: [Diagnostic LP / Therapeutic LP / Attempted / Aborted]

Pre-Procedure

Indication: [Specific clinical reason for lumbar puncture] (Do not use vague terms; clearly state the diagnostic or therapeutic indication.)

Risk Assessment:

• Neurologic risk screen: [Pertinent neurologic exam findings; level of consciousness; papilledema status if assessed] (If risk factor present, document mitigation strategy. If information unavailable, state explicitly.)
• Bleeding risk: [Anticoagulants/antiplatelets with last dose if known; known coagulopathy; most recent platelet count and INR if reviewed] (If abnormal, document mitigation strategy. If labs unavailable, state explicitly with clinical rationale.)
• Anatomic factors: [Prior lumbar surgery; scoliosis; positioning limitations] (If present, document mitigation strategy.)
• Imaging reviewed: [Head CT/MRI status and relevant findings (e.g., no mass effect or midline shift) / Imaging not obtained with rationale]

Consent: [Consent obtained from patient / Consent obtained from surrogate (relationship) / Proceeded under emergency exception]; [Written consent on file / Verbal consent with witness name and role]. (Document that procedure, risks, benefits, and alternatives were discussed. If emergency exception, document why consent could not be obtained and why delay would increase risk.)

Time-Out: [Standardized time-out performed confirming correct patient, procedure, and intended lumbar region/level / Time-out not performed: reason] (Must be explicitly documented.)

Preparation: Hand hygiene performed. Sterile technique with sterile gloves and drape. Skin antisepsis with [chlorhexidine with alcohol / povidone-iodine / other agent]. Mask worn per infection control guidelines. Local anesthetic: [agent, concentration, volume].

Procedure Details

(Complete this section only if needle insertion was attempted.)

Position: [Lateral decubitus (specify side) / Sitting] (Note any position changes during the procedure.)

Approach and Level: [Midline / Paramedian] approach at [interspace (e.g., L3-L4, L4-L5)]; level identified by [anatomic landmarks / ultrasound / fluoroscopy]. (If exact level uncertain, document as estimated.)

Technical Course:

• Number of attempts: [Number] (Include number of interspaces tried if applicable.)
• Technical difficulties: [Poor landmarks / Patient movement / Dry tap / None / Other]
• Needle: [Atraumatic/pencil-point / Cutting]; [Gauge]
• If aborted: [Reason and patient status post-abortion]

Opening Pressure: [Measured: value in cm H₂O, patient position at measurement, factors affecting accuracy if any / Not obtained: reason (sitting position, no manometer available, patient intolerance, urgent sampling, other)] (Must be explicitly documented even if not obtained.)

CSF Findings: [Appearance: clear/colorless / cloudy / xanthochromic / bloody / initially bloody then clearing]; [Total volume collected in mL]; [Number of tubes]

Studies Sent: [List specific tests ordered, e.g., cell count with differential, protein, glucose (note if paired serum glucose ordered), Gram stain and bacterial culture, viral PCR panel, fungal/AFB culture, oligoclonal bands, cytology] (Avoid phrases like "routine studies." If no CSF obtained, state "No CSF obtained; no studies sent.")

Completion: Stylet replaced prior to needle withdrawal. Dressing applied. Patient [tolerated procedure well / describe response].

Post-Procedure

Outcome and Complications: [No immediate complications / Complication(s): traumatic tap, bleeding concern, persistent paresthesia, vasovagal event, immediate headache, required escalation of care (specify)] (Must be explicitly documented; do not leave blank or omit.)

Instructions: [Activity guidance per institutional policy]. Patient advised to seek urgent evaluation for: severe postural headache, fever, worsening back pain, new weakness or numbness, bowel or bladder dysfunction, or persistent site leak. [Site care instructions if applicable].

Disposition: [Remained in ED / Admitted to (service/location) / Discharged]; Follow-up of pending CSF results (cultures, PCR) by [responsible clinician/team].