Paracentesis with US guidance

For a complete description of how to perform an Ultrasound Guided Paracentesis, click here.


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 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.

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