Native Kidney Biopsy Procedure Note

Procedure: Percutaneous native kidney biopsy — [right / left / bilateral] (If bilateral, briefly state rationale.)

Date and Time: [Date and time of procedure]

Location: [Procedure location]

Operator(s): [Primary operator], [Assistant(s) if applicable]

Service: [Nephrology / Interventional Radiology]

Indication: [AKI / Nephrotic syndrome / Proteinuria–hematuria / CKD evaluation / Systemic disease workup / Other]

Indication and Clinical Context

[Brief summary of why biopsy is indicated now] (2–4 sentences summarizing the clinical question, timing, and relevance. Include factors impacting approach or bleeding risk if pertinent, such as blood pressure control, renal function, anemia, and anatomic considerations like solitary kidney or cortical cysts. Reference prior imaging if relevant. If indication details are documented elsewhere, reference that note succinctly.)

Pre-Procedure Assessment

Hemostasis labs (Include values and timestamps. If any value is pending, document pending status and rationale for proceeding.)

• Platelet count: [value] ([date/time])
• INR: [value] ([date/time])
• Hemoglobin: [value] ([date/time])
• Creatinine / eGFR: [value] / [value] ([date/time])

Anticoagulation and antiplatelet status (Document by agent. If the patient is not on any antithrombotic agents, state explicitly. Do not infer absence if history is uncertain; document uncertainty and verification steps taken.)

• Aspirin: [not taking / taking] — Last dose: [date/time]; Held per protocol: [yes / no / N/A]; Planned restart: [timeframe/criteria]
• P2Y12 inhibitor: [agent name / not taking] — Last dose: [date/time]; Held per protocol: [yes / no / N/A]; Planned restart: [timeframe/criteria]
• Warfarin: [taking / not taking] — Last dose: [date/time]; INR goal for procedure: [value]; Held per protocol: [yes / no / N/A]; Planned restart: [timeframe/criteria]
• DOAC: [agent name / not taking] — Last dose: [date/time]; Held per protocol: [yes / no / N/A]; Planned restart: [timeframe/criteria]
• Heparin/LMWH: [agent and route / not taking] — Last dose: [date/time]; Held per protocol: [yes / no / N/A]; Planned restart: [timeframe/criteria]
• Other antithrombotics: [agent / none] — Details: [last dose/hold/restart plan]
• Summary: [No antithrombotic agents / Antithrombotic history uncertain — verification steps and plan]

Informed Consent

[Consent obtained prior to procedure / Consent documentation pending] (Never infer consent was obtained without explicit information.)

• Consenting party: [patient / legally authorized representative]; Interpreter used: [yes — language/mode / no]
• Discussion included: indication, benefits, risks, and alternatives; questions answered
• Material risks reviewed: bleeding (hematoma, gross hematuria, potential need for transfusion or intervention), pain, infection, inadequate tissue requiring repeat biopsy, and rare injury to adjacent structures

Pre-Procedure Verification and Time-Out

Pre-procedure verification: [completed / not completed] (Verify patient identity, procedure, site/laterality, allergies, and pertinent labs/imaging.)

Time-out: [performed immediately prior to needle insertion / pending]; Site marking: [performed / not applicable]

Sedation and Anesthesia

Approach: [Local anesthesia only / Moderate sedation / Anesthesia-managed sedation / General anesthesia]

• If local anesthesia only: Agent/concentration/total dose: [agent, concentration, volume/dose]; Adjunct analgesia/anxiolysis: [agent and dose / none]
• If moderate sedation: Sedation provider: [name/role]; Medications/doses/routes: [list or reference MAR/sedation record]; Monitoring per protocol: [yes]
• If anesthesia-managed or general anesthesia: [Type and airway status]; Details: see anesthesia record

Procedure

• Position: [prone / supine anterolateral / lateral decubitus] (If non-prone, document rationale.)
• Preparation: [Skin prep solution], sterile technique maintained, sterile draping applied
• Imaging: Guidance: [real-time ultrasound / ultrasound localization / CT]; Target kidney: [right / left]; Target pole: [lower / upper / interpolar]
• Technique:
  • Device: [spring-loaded automated biopsy device]; Needle gauge: [16G / 18G / other]
  • Access: Coaxial/introducer technique: [used / not used]; Number of passes: [number]; Number of cores obtained: [number]
  • Adjuncts: [tract plug / gelfoam / none]; Post-biopsy ultrasound: [performed — findings / not performed]
• Hemostasis: [Manual pressure duration], Dressing: [type]; Estimated blood loss: [mL / minimal]; Hemodynamics at completion: [stable / specify]

Specimens

• Total cores: [number]
• Allocation: [Light microscopy / Immunofluorescence / Electron microscopy / Per renal pathology protocol]
• Specimen labeling verified with two identifiers: [yes]; Handoff to pathology: [time/personnel]
• Specimen adequacy: [confirmed adequate by on-site assessment / adequacy to be determined by pathology] (Do not assert adequacy unless confirmed at time of procedure.)

Complications and Immediate Outcomes

• Immediate complications: [no immediate complications observed / describe event(s)] (Use "no immediate complications observed" rather than "no complications" to acknowledge possibility of delayed events.)
• Interventions required: [none / analgesia / IV fluids / imaging / escalation of care — specify]
• Patient tolerance: [tolerated well / discomfort — describe]

Post-Procedure Plan

• Disposition: [PACU / observation unit / inpatient bed]; [admit / discharge] — Rationale: [brief rationale]
• Monitoring: Bed rest: [duration]; Vital signs: [frequency]; Urine monitoring for hematuria: [yes — frequency / no]; Labs/imaging: [protocol-driven timing / symptom-triggered per institutional policy]
• Medication restart: Anticoagulants/antiplatelets to resume: [agent(s) / none applicable]; Timing/criteria: [timeframe and conditions]; Responsible for restart decision: [service/clinician]
• Discharge instructions (If applicable):
  • Activity: avoid strenuous activity/heavy lifting for [duration]
  • Return precautions: gross hematuria, syncope/dizziness, worsening flank pain, fever, inability to void
  • Follow-up: pathology results communication [who/when]; Clinic follow-up: [scheduled / to be scheduled]