Paracentesis with US guidance
For a complete description of how to perform an Ultrasound Guided Paracentesis, click here.
Name:
Exam Date:
Indication:
CPT Code/s:
Procedure start time:
Procedure end time:
Attending radiologist: _______________ was present for and participated in the entirety of the procedure.
Resident radiologist:
Consent:
After the explanation of the risks, benefits, alternatives and possible complications, written and verbal informed consent was obtained from the patient and placed in the chart.
Procedure:
The patient was identified in the ultrasound suite and placed in the supine position. The bilateral lower quadrants were interrogated with ultrasound. The _____ lower quadrant demonstrated a small/medium/large fluid pocket. An appropriate site was chosen for needle entry and this area was marked, prepped, and draped in the usual sterile fashion. Local infiltrative anesthesia was achieved with 1% Lidocaine without Epinephrine. A 19-gauge Yueh Centesis catheter was advanced through the abdominal wall under continuous negative pressure until serous/serosanguinous/sanguinous fluid was aspirated. The needle was removed and the catheter was advanced. Approximately _____ ml of fluid was removed. The catheter was then removed, hemostasis was achieved, and a soft dressing was applied to the entry site. Post-procedural images revealed no immediate complications and significantly/moderately/mildly decreased residual ascites. The patient tolerated the procedure well and had no immediate complications.
(The aspirated fluid was hand delivered to the lab and/or pathology for further testing.)
The patient was discharged home/ to the general medical floor with appropriate post procedural orders. (They were instructed to return to the ER with symptoms of severe abdominal pain.
Impression:
Technically successful Ultrasound guided paracentesis yielding _____ mL of serous/serosanguinous/sanguinous fluid.
Name:
Exam Date:
Indication:
CPT Code/s:
Procedure start time:
Procedure end time:
Attending radiologist: _______________ was present for and participated in the entirety of the procedure.
Resident radiologist:
Consent:
After the explanation of the risks, benefits, alternatives and possible complications, written and verbal informed consent was obtained from the patient and placed in the chart.
Procedure:
The patient was identified in the ultrasound suite and placed in the supine position. The bilateral lower quadrants were interrogated with ultrasound. The _____ lower quadrant demonstrated a small/medium/large fluid pocket. An appropriate site was chosen for needle entry and this area was marked, prepped, and draped in the usual sterile fashion. Local infiltrative anesthesia was achieved with 1% Lidocaine without Epinephrine. A 19-gauge Yueh Centesis catheter was advanced through the abdominal wall under continuous negative pressure until serous/serosanguinous/sanguinous fluid was aspirated. The needle was removed and the catheter was advanced. Approximately _____ ml of fluid was removed. The catheter was then removed, hemostasis was achieved, and a soft dressing was applied to the entry site. Post-procedural images revealed no immediate complications and significantly/moderately/mildly decreased residual ascites. The patient tolerated the procedure well and had no immediate complications.
(The aspirated fluid was hand delivered to the lab and/or pathology for further testing.)
The patient was discharged home/ to the general medical floor with appropriate post procedural orders. (They were instructed to return to the ER with symptoms of severe abdominal pain.
Impression:
Technically successful Ultrasound guided paracentesis yielding _____ mL of serous/serosanguinous/sanguinous fluid.