Paracentesis Procedure Note

Date/Time: [Date; Start time - End time]

Location: [Unit/Room]

Operator(s): [Primary operator; Assistant(s) if any]

Patient Context: [One-line clinical summary linking to indication]

Procedure Type: [Diagnostic / Therapeutic / Both]; [Elective / Urgent / Emergent]

Indication

[Clinical rationale for paracentesis] (Include whether diagnostic for new/worsening ascites or suspected SBP, therapeutic for symptom relief, or both. Mention pertinent findings such as abdominal distension, dyspnea, fever, or imaging evidence. Write as 2–3 sentences.)

Safety Review

• Bleeding risk: [Anticoagulant/antiplatelet agent(s), last dose; platelet count and INR if reviewed; decision to proceed/hold/reverse]
• Site assessment: [Skin integrity, infection concerns, scars, or drains at planned site]
• Anatomic considerations: [Prior surgery, hernias, organomegaly, bladder status]

Consent

[Consent obtained from patient / surrogate (relationship)]. Risks (bleeding, infection, bowel perforation, hypotension, persistent leak), benefits, and alternatives discussed; questions answered; consent obtained. (If emergent and consent not obtainable, document emergency rationale.)

Time-Out

Time-out completed confirming patient identity, procedure, site/laterality [LLQ / RLQ / other], allergies, anticoagulation status, and equipment availability. Team present: [operator, nursing, others].

Procedure

Positioning: [Supine / Semi-recumbent with degree of elevation / Lateral tilt if used]

Bladder status: [Voided / Foley in place / Confirmed empty by ultrasound]

Skin preparation: [Prep agent] with sterile draping.

Local anesthesia: [Agent, concentration, volume]

Puncture site: [Quadrant and anatomic reference, e.g., LLQ lateral to rectus]

Device: [Needle/catheter type and gauge]; Z-track: [yes / no]; Attempts: [number]

Entry: [Aspiration of fluid confirmed; catheter advanced; needle removed intact]

Diagnostic sample: [Volume collected] (if applicable)

Therapeutic drainage: [Gravity / Vacuum-assisted]; Total volume removed: [X.X L]; [Reason for early termination if applicable]

Closure: Catheter removed intact; [hemostasis method]; [dressing type applied].

(If procedure aborted or unsuccessful, document reason, patient condition, and next steps.)

Ultrasound

[Static site marking / Real-time guidance / Not used—landmark technique employed]. (If used: document fluid pocket adequacy, structures avoided, depth if relevant, and confirm images archived. Reference separate US report if generated.)

Fluid Characteristics & Specimens

Gross appearance: [Clear-straw / Cloudy / Bloody / Chylous / Bilious]

Studies sent:

• Cell count with differential
• Albumin, total protein (serum albumin for SAAG: [obtained / not obtained])
• Culture (bedside inoculation into blood culture bottles: [yes / no])
• [Additional studies based on clinical suspicion: cytology, triglycerides, amylase, creatinine, ADA, AFB/fungal] (Include only tests actually ordered.)

(If no studies sent, document rationale.)

Albumin Replacement

Volume removed: [X.X L]. [Albumin ordered: formulation, dose, timing / Albumin not indicated—rationale / Not applicable—diagnostic tap, small volume]. (Typical threshold >5 L; typical dosing 6–8 g per liter removed.)

Complications & Tolerance

[Patient tolerance with specific observations]. Estimated blood loss: [minimal / quantified]. Immediate complications: [None / Description with management]. (Document any specimen issues such as culture not obtained or hemolyzed sample.)

Post-Procedure Plan

• Monitoring: [Vital sign frequency, site checks, activity restrictions]
• Albumin: [Infusion timing and dose if ordered]
• Follow-up: [Labs, imaging, or fluid results to follow]
• Management: [Diuretic adjustments, empiric antibiotics if SBP suspected, other]
• Escalation triggers: [Hypotension, bleeding, increasing pain, persistent leak]