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OVERVIEW
Once a procedure will be performed it is important to conduct a focused (yet comprehensive) chart review so that one can prepare a history and physical note and also review any information that is relevant for the procedure. While performing a paracentesis may seem like a relatively basic procedure (in comparison to some of the other procedure that are conducted in the field of interventional radiology) a through chart review is still beneficial prior to conducting the procedure. This page will focus on features fo the chart review that are specific to the paracentesis procedure however for more details on performing a chart review for IR procedures refer to the following page: Interventional Radiology Fundamental Peri-Procedural Tasks: Performing A Chart Review.
This page will focus on features fo the chart review that are specific to the paracentesis procedure however for more details on performing a chart review for IR procedures refer to the following page: Interventional Radiology Fundamental Peri-Procedural Tasks: Performing A Chart Review.
RADIOLOGY PROCEDURE NOTE TEMPLATE
Keep in mind that when you are performing a chart review it is a great time to also begin drafting your history and physical report. An example of a note template is shown below that you can use:
RADIOLOGY-PROCEDURE-HP-TEMPLATE-EPIC
WHAT IS THE PARACENTESIS BEING ORDERED FOR (INDICATION FOR PROCEDURE)
Perhaps one of the initial things to establish is if this patient’s paracentesis is diagnostic, therapeutic, or BOTH. For more review about paracentesis indications please see this page here.
In the case of a diagnostic paracentesis it is important to make sure you understand all the diagnostic testing that is required for the acquired sample.
HAS THE PATIENT HAD A PRIOR PARACENTESIS?
This topic is also covered in more detail on the section which covers how to review prior imaging for a paracentesis.
It is also useful to look back in the patient’s chart and see if they have ever had a paracentesis in the past. If they have there are a few things to keep in mind and review:
- How long ago was their last paracentesis (how often do they get a paracentesis, and is it on a regular interval)? This can give a sense of timing of paracentesis and the interval they require for the drainage of their ascites.
- How much volume was removed during their last paracentesis? Combined with how long ago this was done, knowing the volume drained previously can help inform how much you may expect during their current procedure.
- What did the ascites look like? This is often charted with the volume removed. This can also set expectations on what you might see when draining their ascites for the current procedure.
- Was albumin given and if so, how much? While there are guidelines for the administration of albumin in the setting of paracentesis it is always useful to contextualize what patients have received previously (and how it was tolerated).
DOES THIS PATIENT EVEN HAVE ASCITES?
This topic is also covered in more detail on the section which covers how to review prior imaging for a paracentesis.
Perhaps the most pertinent question that can be answered by reviewing imaging prior to a paracentesis is to establish if the patient even has ascites to begin with. It may seem obvious that this should be checked, however sometimes patients may have a physical exam that suggests ascites, but on imaging there may not be ascites present. And sometimes, even if there is ascites, the volume may not be large enough to safely perform a paracentesis.
Whenever possible, it can be useful to establish this information with prior diagnostic imaging (instead of bringing down the patient for the procedure, and discovering last minute that there is not any ascites/enough ascites to drain easily.
Ascites is commonly detected by ultrasound or by CT scan, and these imaging studies should be used to confirm its presence whenever possible.
Page Updated: 04.14.19