Procedure Note

Procedure: Lumbar Puncture

Physician(s):
Indication:
Anesthesia: 1% Lidocaine w/ epinephrine

Informed consent was obtained from the patient/patient’s parent(s). A time-out was completed, verifying correct patient, procedure, site,
positioning, and implant(s) or special equipment if applicable. The area was prepped and draped in the usual sterile fashion. Using standard
landmarks, a spinal needle was inserted in the L3-L4 innerspace. The stylet was removed and the opening pressure was measured at [ ?? ] cm of
water. [ ?? ] ml clear/cloudy/xanthochromic/bloody fluid was collected and sent for cell count, glucose, protein, gram stain, and bacterial culture.

Fluid was also sent for:

The patient tolerated the procedure well.

Complications: None

Blood loss: Minimal

Dr. [attending’s name] was present/immediately available by telephone during the entire procedure.

Dictation Job #: