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Lumbar Puncture Procedure Note

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In Attendance (Y/N): _
Consent was obtained from _ prior to the procedure. Indications, risks, and benefits were explained at length. 
A time-out was performed. My hands were washed immediately prior to the procedure. I wore a surgical cap, mask with protective eyewear, sterile gown and sterile gloves throughout the procedure. The patient was placed in the _ position with help from the nursing staff. The area was cleansed and draped in usual sterile fashion using betadine scrub. Anesthesia was achieved with 1% lidocaine. A 20-gauge 3.5-inch spinal needle was placed in the _ lumbar interspace. On the _ attempt, _ colored cerebral spinal fluid was obtained. The opening pressure was _ cm H20. CSF was collected into 4 tubes. These were sent for the usual tests, including 1 tube to be held for further analysis if needed. A sterile bandaid was placed over the puncture site. The patient had no immediate complications and tolerated the procedure well.  Estimated blood loss was _.
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  • All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only.  Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient.  Merely copying and pasting a prewritten note into a patient's chart is unethical, unsafe, and possibly fradulent.