How to write a lumbar puncture procedure note

This fluid, which surrounds the brain and spinal cord, helps cushion them against sudden jarring and minor injury. For a spinal tap lumbar puncturea sample of cerebrospinal fluid is withdrawn with a needle and sent to a laboratory for examination. The cerebrospinal fluid is checked for evidence of infections, tumors, and bleeding in the brain and spinal cord. These disorders may change the content and appearance of the cerebrospinal fluid, which normally contains few red and white blood cells and is clear and colorless.

How to write a lumbar puncture procedure note

However, documentation of pre-procedural informed consent processes would not be significantly different in cases where the LP proved to be ultimately unsuccessful. Since the study did not focus on the LP procedure itself successful or not successfulthe nature of the pre-procedure consent would not be altered by the subsequent result of the LP procedure.

Documentation could well err in both directions of under- and over-reporting. On the other hand, over-reporting is made easier with the availability of EHR templates. In either case, the documentation should reflect the details of the informed consent conversation as it actually transpired and remains the only basis on which the quality and completeness of the process can be judged after the fact.

We selected 3 EDs in our local area to identify the documentation practices for LP consent. Though there is significant variability among these EDs and their patient populations, our results may not be generalizable to all EDs across the U. During the study period, 2 of the 3 EDs had emergency medicine residents who worked with assigned attending physicians for the LP procedure.

Attending physicians ultimately had the primary responsibility for assuring that LP consent was obtained and documented in the medical record. Patients who present to the ED and require LPs are deemed to be urgent or emergent, addressing this issue of the patient's condition and urgency of the procedure.

Documentation of informed consent may not be a reliable evaluation of what actually took place prior to the LP. However, the current standard of care in this area is to obtain a signed consent form, with documentation about the discussion of the purpose, risks, benefits, and alternatives to the procedure.

Our only avenue for obtaining informed consent is what this study reviews, i. Our data also showed that the rates of documentation for pediatric patients were not superior to their adult counterparts. Documentation of the educational component of the informed consent process, as measured by documentation of an explanation of the LP, the use of educational material, and LP-specific discharge information, was rarely found in the EHR.

Our study of informed consent for lumbar puncture in the ED for all patients adults and pediatrics is the first of its kind to our knowledge. Despite the expectation for a signed informed consent in every chart, the data showed that this is not always achieved.

Generalized ED consent was obtained for the vast majority of patients who presented to the ED during the study period.

The presence of this generalized consent may have been deemed by EPs to be adequate for procedures like an LP, leading to no further effort to obtain informed consent through the use of an LP-specific consent form.

Variables that decrease the perceived need for seeking LP-specific informed consent by physicians in the ED setting could include the following: Our overall compliance for documenting the various aspects of informed consent purpose, risk, benefits, and alternatives was found to be similar to prior studies performed in different settings: The use of a standardized form to obtain consent could help improve compliance, though a review of hospitals nationwide found that the content of informed consent forms for procedures in those hospitals was inadequate for addressing the standards for informed consent.

Our data showed that the compliance rate for documenting informed consent for pediatric patients undergoing an LP was not superior to that for adult patients.

Informed consent for the pediatric population has some unique challenges. However, our results did not support our hypothesis. Our pediatric results are generally consistent with reports from other facilities.

Further work is needed to improve the documentation rates of informed consent for pediatric, as well as adult, patients.

how to write a lumbar puncture procedure note

Documentation of various aspects of patient education with regard to the LP was also found to be inadequate in our study. Our EDs have not used educational tools for an LP, as have been implemented in other settings for improving informed consent. These tools include supplemental written educational forms, video tools, or computer-based education.

When to do a lumbar puncture

Research suggests that a minority of patients fully read informed consent information, ask questions, or accept a copy of the consent document.3 days ago · A new subcutaneous intrathecal catheter system may be a safe and relatively well-tolerated alternative to lumbar puncture for delivering nusinersen to adults and children with spinal muscular atrophy.

Please note that hand written applications will not be accepted. CV Template Please write the total number of times you have carried out Acute Respiratory Distress Lumbar Puncture performed Hip Replacement.

Procedure Note Procedure - Lumbar Puncture Indication - meningitis Anesthesia - local 1% lidocaine w/ epi Informed consent was obtained from the patient's mother. The area was prepped and draped in the usual sterile fashion.

Using landmarks, a 22 guage spinal needle was. A lumbar puncture or spinal tap is a diagnostic and/or therapeutic procedure. Learn more about reasons for the procedure, risks, and what to expect.

Why might I need a lumbar puncture?

A lumbar puncture procedure may be helpful in diagnosing many diseases and disorders, including: Please note: You will be unable to drive for 24 hours after the procedure.

If you are .

how to write a lumbar puncture procedure note

procedure where a needle is inserted into the spinal column between the lumbar vertebrae; preformed for both diagnostic and therapeutic reasons. Concepts Diagnostic Procedure (T), Therapeutic or Preventive Procedure (T). The procedure was described to the patient in the presence of ***.

All the indications and potential side effects of the procedure were discussed in details (including but not limited to risk of bleeding, infection, nerve injury and post LP headache).

Procedure Notes |