Thoracentesis Procedure Note

Procedure: Thoracentesis

Date/Time: [Start time] to [End time]

Location: [ED / ICU / ward / procedure suite / other: specify]

Operator: [Operator name and credentials] (If not documented, enter "Not documented".)

Laterality: [Right / Left / Bilateral] (If bilateral, document each side separately in Site Selection & Ultrasound, Findings, Specimens Sent, and Complications.)

Patient Position: [Patient position, e.g., seated leaning forward, lateral decubitus]

Indication & Clinical Context

[Indication for thoracentesis] [Diagnostic and/or therapeutic intent] [Relevant clinical context affecting risk or approach] (Compose 2–4 concise sentences focused on procedure justification. Include clinically relevant factors such as mechanical ventilation, significant lung disease, suspected malignancy or infection, anticoagulation status, and prior ipsilateral pleural interventions if explicitly documented.)

Pre-procedure Review

• Imaging reviewed: [CXR / CT / ultrasound] confirming [side and target findings] (State "Not indicated" if not applicable; "Unknown" if clinically relevant but unknown.)
• Bleeding risk assessment: [Anticoagulants/antiplatelets and peri-procedure management] [Relevant labs if obtained, or "Labs not indicated" with brief rationale]
• Allergy review: [Allergy status for local anesthetics and skin prep agents] (State "No known allergies" or list relevant allergies.)

Consent

[Consent obtained from patient / surrogate (specify relationship)] [Risks discussed: pneumothorax, bleeding, infection, pain, vasovagal reaction, re-expansion pulmonary edema] [Alternatives discussed and questions answered] (If emergent and consent not obtainable, document the emergent indication and why consent could not be obtained.)

Time-out

Time-out performed with verification of correct patient, correct procedure (thoracentesis), correct side ([Right / Left]), allergies reviewed, and relevant imaging available.

Site Selection & Ultrasound

(For bilateral procedures, duplicate this section for each side.)

Side: [Right / Left]

• Anatomic site: [Intercostal space number] at [posterior axillary / midaxillary / scapular] line; [above-the-rib approach confirmed / not feasible: reason]
• Skin marked: [Yes / No]
• Ultrasound: [Used / Not used]
  • If used: [Pre-procedure localization/marking only / Real-time guidance during needle advancement / Both]; [Key findings: fluid pocket accessibility, estimated depth if measured, visualization of diaphragm and adjacent structures]; Images saved: [Yes / No / Not applicable]
  • If not used: [Reason, e.g., emergent, equipment unavailable]

Procedure

[Skin preparation and sterile draping] [Local anesthesia: agent, total dose/volume] [Needle/catheter type and size] [Number of attempts and any redirections] [Entry approach: above-the-rib technique confirmed, or document if not feasible and why] [Drainage method: manual syringe aspiration / gravity drainage] [Patient tolerance and any symptoms prompting pause or stop] [If stopped before complete drainage, document reason: symptoms / planned volume limit / no further fluid obtainable] (For bilateral procedures, document each side in a separate paragraph.)

Findings

(For bilateral procedures, document each side separately.)

• Side: [Right / Left]
• Volume removed: [Total mL]
• Fluid character: [clear / straw / amber / cloudy / purulent / bloody / serosanguinous / chylous] [Odor if abnormal]

Specimens Sent

[List studies sent, e.g., cell count/differential, protein, LDH (± paired serum), glucose, pH, Gram stain/culture, cytology with volume, AFB/fungal cultures, triglycerides, amylase] (Include only studies actually sent. For bilateral procedures, label specimens by side. If no studies sent, state "No pleural fluid studies sent" with brief rationale.)

Complications

[No immediate complications; patient reassessed post-procedure] OR [Complication description: what occurred, evaluation performed (e.g., bedside lung ultrasound for lung sliding, CXR), and interventions taken] (Do not imply absence of pneumothorax unless assessed by appropriate method. For bilateral procedures, document complications by side if applicable.)

Post-procedure Plan

• Monitoring: [Vital signs frequency, pulse oximetry, pain management plan]
• Imaging: [Routine CXR not indicated per protocol; will image if symptoms develop] OR [CXR / lung ultrasound planned: timing and indication]
• Results follow-up: [Responsible clinician/team for pending results] [Notification plan for critical findings]
• Disposition: [Remained inpatient / Discharged with return precautions]

Attestation

[Operator signature]
[Printed name and credentials]

(General instruction: If laterality, site, or operator identity is not documented in the dictation, do not infer—enter "Not documented" to flag for correction.)