Paracentesis/Thoracentesis Procedure Note

Date/Time: [Start date and time of procedure]

Location: [bedside / procedure room / IR suite / clinic / other]

Primary Operator: [Name and credentials]

Assistant(s): [Name(s) and credentials / none]

Procedure(s) Performed: [paracentesis / thoracentesis / both]

Indication

[Brief clinical indication] (1–3 sentences stating the primary indication; specify diagnostic vs therapeutic intent and include pertinent imaging findings if relevant.)

Pre-procedure Assessment

• Anticoagulant/Antiplatelet status: [agent(s), last dose, peri-procedural management / none]
• Relevant labs: [platelets: __; INR: __; hemoglobin: __; date obtained] / [not obtained—clinically not indicated] (If not obtained, explicitly state rationale.)
• Allergies: [local anesthetics / antiseptics / none]
• Other relevant risk factors: [coagulopathy, abdominal wall varices, prior surgery, mechanical ventilation, etc. / none] (Only include if clinically relevant.)

Consent

[written / verbal / emergent or implied] (Document that risks, benefits, alternatives, and opportunity for questions were discussed. If emergent/implied, provide clinical justification.)

Interpreter: [not required / language: __; interpreter ID: __]

Time-out

(Performed immediately prior to the procedure.)

• Patient identity confirmed: [Yes]
• Procedure(s) confirmed: [paracentesis / thoracentesis / both]
• Correct site and laterality confirmed: [Right / Left / Not applicable] (Laterality mandatory for thoracentesis.)
• Allergies reviewed: [Yes]
• Anticoagulation status reviewed: [Yes]

Ultrasound

(This field must be explicitly documented—never leave ambiguous.)

Use: [not used (reason: __) / used for site selection and marking only / used with real-time needle guidance]

• Key findings: [fluid pocket location, depth, size; adjacent structures] (For paracentesis, note if Doppler used to avoid abdominal wall vessels.)
• Images saved: [Yes / No]

Paracentesis

(Include this section only if paracentesis was performed.)

• Intent: [diagnostic / therapeutic / both]
• Position: [supine / slight head elevation / other]
• Site: [LLQ / RLQ / midline / other]; ultrasound-selected: [Yes / No]
• Technique: [skin antisepsis agent]; sterile technique; [Z-track / Seldinger / direct insertion]
• Local anesthetic: [agent, concentration, volume]
• Needle/catheter: [type, gauge, length]
• Attempts: [number]; difficulty: [none / describe]
• Volume removed: [__ mL / __ L] (Required.)
• Fluid appearance: [clear / cloudy / bloody / chylous / other]; stopped early: [No / Yes—reason: __]
• Specimens sent: [none—therapeutic only / cell count with differential, albumin (SAAG), total protein, Gram stain/culture, cytology, other: __]
• Bedside culture inoculation: [Yes / No / not applicable] (If diagnostic, document whether ascitic fluid was inoculated into blood culture bottles at bedside.)
• Albumin replacement: [not applicable (≤5 L) / ordered: ___ g of ___% albumin / administered: ___ g of ___% albumin] (Document if >5 L removed.)

Thoracentesis

(Include this section only if thoracentesis was performed.)

• Laterality: [Right / Left] (Required—patient safety field.)
• Intent: [diagnostic / therapeutic / both]
• Position: [sitting upright leaning forward / lateral decubitus / other]
• Site: [intercostal space __, __ line]; ultrasound-selected: [Yes / No]
• Technique: [skin antisepsis agent]; sterile technique; needle introduced over superior rib margin
• Local anesthetic: [agent, concentration, volume]
• Needle/catheter: [type, gauge, length]
• Drainage method: [manual aspiration / gravity / vacuum or suction (rationale: __)]
• Attempts: [number]
• Volume removed: [__ mL / __ L] (Required.)
• Fluid appearance: [serous / cloudy / purulent / bloody / other]
• Symptoms during drainage: [none / cough / chest pain or tightness / dyspnea / other]; action: [continued / paused / stopped]
• Specimens sent: [none—therapeutic only / cell count, protein, LDH, glucose, pH (collection: __), Gram stain/culture, cytology, other: __]
• Post-procedure imaging ordered: [Yes—indication: __ / No—patient asymptomatic and low risk] (Required—explicitly document decision.)

Complications and Patient Response

Complications: [none / bleeding / hypotension / persistent leak / suspected pneumothorax / pain / organ injury concern / other: __] (Required—if present, describe interventions taken.)

Patient tolerance: Vitals [stable / unstable: __]; oxygen requirement [unchanged / improved / increased]; [symptomatic improvement noted / not applicable]

Post-procedure Plan

• Monitoring: [vital sign and puncture site check frequency and duration]; [respiratory monitoring if thoracentesis]
• Dressing: [type]; removal: [timing/instructions]
• Activity: [restrictions / as tolerated]
• Follow-up: [fluid study result review plan]; [additional treatments or consultations]; [return precautions]

(Global requirement: The following must be explicitly documented and never omitted or inferred—procedure type, date/time, operator, indication, consent, time-out, ultrasound use, site and laterality for thoracentesis, anesthetic, volume removed, complication status, and post-procedure monitoring. If not applicable, state explicitly.)