Thoracentesis with US guidance


Exam Date:


CPT Code/s:

Procedure start time:

Procedure end time:

Attending radiologist: _______________ was present for and participated in the entirety of the procedure.

Resident radiologist:

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.

The patient was identified in the ultrasound suite and placed in the seated position. The posterior thorax was interrogated with ultrasound. The right/left thorax demonstrated a small/medium/large fluid collection. 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 into the pleural cavity 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 ultrasound images revealed no immediate complications and a significantly/moderately/mildly decreased residual effusion. 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 post-procedureal upright inspiratory and expiratory chest radiographs revealed no evidence for pneumothorax)

The patient was discharged home/ sent to the general medical floor with appropriate post procedural orders. (They were instructed to return to the ER should any symptoms of shortness of breath or chest pain occur.)

Technically successful Ultrasound guided thoracentesis yielding _____ mL of serous/serosanguinous/sanguinous fluid.