BONE MARROW ASPIRATE/BIOPSY PROCEDURE NOTE

Andy Nguyen, M.D. / UT-Medical School at Houston, Pathology/ Last Revision on: 7/6/2011

Bone marrow aspiration and biopsy procedure

Hematopathology

Date/ Time: xxxx xx:xx

Indication: xxxx

Referred by: xxxx, M.D.

- Time-out was called to confirm: patient’s name and date of birth, procedure, side and site of biopsy, safety procedures followed.

- Performed by: self.

- Attending pathologist: xxx, M.D.

- Other physicians present: xxxx, xxxx (Pathology resident)

- Informed consent: signed by patient.

- Aspiration and biopsy site: [left][right] superior posterior iliac crest.

- Patient position: [prone] [right lateral decubitus][left lateral decubitus]

- Preparation and technique: sterile preparation of site with Betadyne, Chloraprep, draped to expose aspirate/biopsy area, local anesthesia with 1% lidocaine (approximately 10ml), frequent pressure application on incision to maintain hemostasis.

- Tissue obtained: bone marrow aspirate and biopsy were successfully obtained in sterile manner.

- Toleration of procedure and any complications: slight localized bleeding (<1ml). Patient tolerated procedure well with minimal pain.