Lumbar Puncture Procedure Note Template

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A diagnostic lumbar puncture may be performed during the initial staging or follow-up evaluation of a hematologic or solid malignancy when one suspects CNS involvement. The indications for lumbar puncture vary among different medical and surgical disciplines, though obtaining a sample for cerebrospinal fluid analysis is the most common one. A lumbar puncture is an invasive test designed to access the subarachnoid space in the lower spinal canal.

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SUMMARY: Lumbar puncture has, for many years, been the responsibility of the internal medicine physician or the neurologist.

The evaluation of the spinal fluid is usually necessary for the definitive diagnosis and to help make optimal treatment decisions (such as the appropriate choice of antibiotics). for which a lumbar puncture is indicated.

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Merely copying and pasting a prewritten note into a patient's chart is unethical, unsafe, and possibly. It's common to encounter bone while looking for a path to the CSF; When bone is encounter, leave the needle in place, and carefully assess the alignment of the needle Check if the needle is angled too far to the right or left. Especially note if a patient requested you stop the procedure, as this is a relevant distinction from being otherwise unable to obtain a sample.