Thoracentesis Procedure Note

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 and the chest x-ray was reviewed, the appropriate side was confirmed and marked. 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 prepped and draped in a sterile manner using chlorhexidine scrub after the appropriate level was percussed and confirmed by ultrasound. 1% lidocaine was used to anesthesize the skin, subcutaneous tissue, superior aspect of the rib periosteum and parietal pleura. A finder needle was then introduced over the superior aspect of the rib to locate the pleural fluid; _ colored fluid was aspirated at a depth of approximately _ cm. A 10-blade scalpel was used to nick the skin at the insertion site. The Safe-t-Centesis needle was then introduced through the skin incision into the pleural space using negative aspiration pressure and the red colometric indicator to confirm appropriate positioning of the needle. The thoracentesis catheter was then threaded without difficulty. _ ml of _ colored fluid was removed without difficulty. The catheter was then removed. No immediate complications were noted during the procedure. A post-procedure chest x-ray is pending at the time of this note. The fluid will be sent for studies.  Estimated blood loss is _.
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