Lumbar Puncture
Date: <____>
Time: <____>
Indication: Altered Mental Status
Resident: <____>
Attending: <____>
A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in the <LEFT/RIGHT> lateral decubitus position in a semi-fetal position with help from the nursing staff. The area was cleansed and draped in usual sterile fashion. 1% lidocaine was used anesthetize the surrounding skin area. A <20-gauge 3.5-inch> spinal needle was placed in the <L3-L4/L4-L5> interspace. Clear cerebral spinal fluid was obtained and the opening pressure was noted to be <?cm>. Four tubes were filled with 4 mL of CSF. These were sent for the usual tests, including 1 tube to be held for further analysis if needed. <Attending/Resident> was present for the entire procedure
Estimated Blood Loss: <____>
The patient tolerated the procedure well and there were no complications.
Other procedure note examples:
- Endotracheal Intubation
- Central Line (CVC) Access
- Arterial Line
- Lumbar Puncture
- Thoracentesis
- Thoracostomy (Chest Tube)
- Swan-Ganz Catheter Placement
Also, thank you to my two favorite websites for helping me write notes in the hospital:
My name is Andrew and I am a first year resident training to be an ophthalmologist. I created ShortWhiteCoats to provide medical students, residents, and the public with all the information I spent so many hours looking for during medical school.
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