Medical Thoracoscopy/Pleuroscopy Procedure Note

Date/Time: [Procedure start time – end time]

Location: [Procedure location]

Laterality: [Right / Left] (Critical safety field; must be explicitly stated. If not documented, write "not documented.")

Patient Position: [Supine / Lateral decubitus / Other]

Primary Operator: [Name, credentials]

Assistant(s): [Name(s) and role(s), or "none"]

Sedation/Anesthesia: [Proceduralist-directed moderate sedation / Monitored anesthesia care / General anesthesia] — [Sedation/anesthesia provider]

Procedure Summary: [Single-sentence summary capturing laterality, diagnostic vs therapeutic elements, biopsy count if obtained, pleurodesis agent and dose if performed, and drain type/size placed]

Indication

[Primary indication and clinical question; key symptoms; pertinent imaging findings with laterality, modality, and date; relevant prior pleural procedures and results; rationale for thoracoscopy over alternatives] (Present in 2–5 concise lines; include only elements available; do not infer missing information.)

Pre-Procedure Verification

Time-out completed: [Time] — Patient identifiers confirmed, procedure and side verified, allergies reviewed, imaging reviewed and available, required equipment available, team agreement documented.

Informed consent: Obtained from [patient / surrogate] covering [procedures consented], [key risks discussed], [alternatives discussed]; patient/surrogate agreed to proceed. (If consent not obtained due to emergency, explicitly document rationale.)

Procedure-relevant risk assessment: [Positioning tolerance]; [sedation suitability and airway risk]; [bleeding risk with anticoagulant/antiplatelet status and last doses, or "unknown" / "not documented" if unavailable]; [baseline respiratory status and oxygen requirement]. (Do not infer anticoagulation status if unknown.)

Sedation

[Sedation technique: Proceduralist-directed moderate sedation / Anesthesia service (MAC or general)]

(If proceduralist-directed moderate sedation, include the following; if anesthesia service provided sedation, state "Sedation provided by anesthesia service; see anesthesia record for details" and omit bullet list.)

• [Pre-sedation airway assessment findings]
• [Medications administered: drug, dose, route, time for each]
• [Monitoring: SpO2, HR, BP, capnography if used]
• [Independent trained observer: name/role]
• [Face-to-face sedation start and end times] (Include if billing moderate sedation.)

Procedure

[Thoracic ultrasound for site selection: yes/no; performed in procedural position: yes/no]. Skin prepped with [agent] and draped in sterile fashion. Port site identified at [intercostal space and anatomical line] using [landmarks/ultrasound]. Local anesthesia with [agent, concentration, total volume] infiltrated into skin, subcutaneous tissue, periosteum, and pleura. Access obtained via [blunt dissection / Seldinger / trocar] through [incision length] incision, creating [number] port(s) at [location(s)].

Upon pleural entry, fluid appeared [serous / serosanguinous / bloody / purulent / chylous]; estimated [volume] drained. [Symptoms during drainage and actions taken, if any].

Thoracoscopic inspection: Parietal pleura [normal / nodular / thickened / plaques with distribution]. Visceral pleura/lung surface [findings]. Diaphragmatic pleura [findings]. Mediastinal pleura [visualized/not visualized; findings]. Adhesions/septations [none / extent; lysis performed if applicable]. Lung re-expansion [complete / partial / poor]; non-expandable lung [not suspected / suspected based on specific findings]. Hemostasis [adequate / measures taken].

Biopsies

(Include only if biopsies performed; omit section entirely if none taken.)

Target: [Parietal pleura with site descriptors]. Technique: [Forceps / cryobiopsy with probe size and freeze time]. Number obtained: [Specific number] (Do not infer if unknown.). Gross adequacy: [Adequate / limited]. Bleeding: [None / extent]; hemostasis achieved with [method]. Specimens labeled: [Anatomical descriptors and container labels].

Pleurodesis

(Include only if pleurodesis performed or planned but deferred; omit section entirely otherwise.)

Agent: [Talc, graded/sterile per formulary / other agent]. Dose: [Specific grams] (Do not infer if unknown.). Method: [Poudrage under direct vision / slurry via chest tube]. Distribution: [Uniform / targeted coverage description]. (If planned but not performed: [Reason—concern for non-expandable lung / patient intolerance / other].)

Drain Placement

Drain type: [Chest tube / Indwelling pleural catheter]

Details: [For chest tube: type, size (Fr), insertion site, secured with suture/holder, connected to water seal or suction at specified pressure, initial output, air leak status. For IPC: brand if required, entry site, immediate drainage volume, dressing applied.]

Post-procedure drainage instructions: [Drain open vs intermittent protocol]; [drainage rate limits per protocol]; [clamping criteria]; [removal criteria including output threshold and timeframe after pleurodesis].

Specimens

[Pleural biopsies to surgical pathology, with flow cytometry if ordered]; [pleural fluid for cytology]; [cell count/differential]; [microbiology: Gram stain, culture, AFB/fungal as indicated]; [chemistry if indicated: protein, LDH, glucose, pH, triglycerides, ADA]. Specimen count verified and labels confirmed.

Complications

[None / Description of adverse events with timing and management: bleeding, hypoxemia, hypotension/arrhythmia, suspected injury, pneumothorax beyond expected, re-expansion pulmonary edema]

Post-Procedure Plan

• Condition: [Stable / other]; [oxygen requirement]; [pain control status]
• Disposition: [PACU / Ward / ICU]
• Analgesia: [Plan or managing service]
• Respiratory monitoring: [Monitoring level and SpO2 target]
• Imaging: [Timing of post-procedure CXR or ultrasound; frequency if incomplete expansion or air leak]
• Drain management: [Water seal vs suction; expected duration; removal criteria]
• Follow-up: [Responsible clinician for pathology results]; [clinic follow-up timing]; [preliminary findings communicated to patient/family]