Paracentesis (updated 01/2019)

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Procedure Note

[FM SPECIAL PROCEDURES CLINIC: ]Paracentesis performed by ultrasound guided imagery

 

INDICATION: [XXXXX].

PRE-PROCEDURE DIAGNOSIS: [XXXXX].

POST-PROCEDURE DIAGNOSIS: [XXXXX].

PROCEDURE OPERATOR: [XXXXX].

ATTENDING PHYSICIAN: [XXXXX].

[ROOM CHARGE: 99215]

[CPT CODE: 49083]

 

CONSENT:

Consent was obtained prior to the procedure. Indications, risks (bleeding, damage to bowel, and infection), and benefits were explained at length.  All questions were answered.  Consent signed.

 

PRE-PROCEDURE SURVEY:

-Labs were reviewed prior to the procedure. The labs showed [XXXXX].

-Examination of the abdomen revealed [tense ascites, positive fluid wave, and dullness to percussion].

-The curvilinear transducer was used to scan the abdomen, and the deepest pocket of fluid was found at the [LLQ] with a depth of [XXXXX cm] before visualizing bowel loops.  This area was marked.

-The linear transducer determined the thickness of the abdominal wall to be [XXXXX cm], and color flow was used to ensure the inferior epigastric vessels were not at the marked site.  

 

PROCEDURE SUMMARY: 

A time-out was performed identifying the correct patient, procedure, site, positioning, and the equipment. My hands were washed immediately prior to the procedure.  I put on a gown and sterile gloves.  The [LLQ] was cleansed and draped in the usual sterile fashion using chlorhexidine scrub.  Anesthesia was achieved with 1% lidocaine with extra attention given to anesthetizing the peritoneum.  A small skin incision with an 11-blade was used to nick the skin.  The paracentesis catheter-over-needle was advanced at 0.25 cm increments with the non-dominant hand while the dominant hand maintained negative pressure on the syringe until [yellow and clear] fluid was aspirated.  The needle was held steady, and the catheter was then advanced toward the pocket of fluid.  The needle was removed.  The catheter was connected to the vacutainer, and [XXXXX liters] of ascitic fluid were drained.  [XXXXX grams of Albumin was given to the patient.]  [Approximately XXXXX mL was sent for laboratory analysis in a sterile urine container.]  [Cultures were inoculated at bedside]. The catheter was removed, and no leaking was noted. A bulky pressure dressing was placed over the puncture wound.  The patient tolerated the procedure well, and there were [no] immediate complications.

 

TOTAL FLUID COLLECTED AND COLOR: [XXXXX].

LABS ORDERED: [XXXXX].

EBL: [XXXXX].

COMPLICATIONS: [XXXXX].

COUNSELING: Throughout the procedure, we counseled the patient regarding adherence with medication and dietary changes. ED and return precautions given.