CaseMark Performing Image Guided Procedures
Documents image-guided biopsy, drainage, and injection procedures with technique and specimens.
Why This Skill Exists
Image-guided procedures — biopsies, drainages, aspirations, and injections — are among the highest-risk activities in radiology, carrying potential for hemorrhage, pneumothorax, infection, organ injury, and procedural failure. The ACR-SIR Practice Parameter for Performing and Interpreting Diagnostic Procedures mandates comprehensive procedural documentation including informed consent, technique details, specimens obtained, complications, and post-procedure care. Inadequate procedure notes are a leading source of liability in interventional radiology malpractice claims.
CMS documentation requirements tie reimbursement to specific procedure-note elements, and The Joint Commission requires Universal Protocol compliance (correct patient, correct site, correct procedure) for all invasive procedures. The Society of Interventional Radiology (SIR) quality-improvement guidelines define complication thresholds for common procedures; documentation must capture enough detail to enable quality review and meet these standards. This skill ensures every image-guided procedure is documented with the completeness required by regulatory, accreditation, and medicolegal standards.
Checkpoint A: Pre-Draft Intake (Mandatory)
- What procedure is being performed? (Default: Specify — biopsy, drainage, aspiration, injection, line placement)
- What imaging guidance is used? (Default: CT, ultrasound, fluoroscopy, or MRI)
- What is the target? (Default: Specific organ, lesion, and location)
- Is informed consent documented? (Default: Required — verify before starting)
- What is the patient's coagulation status? (Default: Check INR, platelets, anticoagulation status)
- Does the patient have relevant allergies? (Default: Contrast, latex, local anesthetic)
- What is the planned sedation level? (Default: Local anesthesia — specify if moderate sedation)
- Are pre-procedure labs adequate? (Default: INR <1.5, platelets >50,000 for most procedures)
Documents to Request
- Signed informed consent form
- Pre-procedure labs (CBC, PT/INR, PTT; creatinine if contrast planned)
- Relevant imaging (CT, US, MRI) showing the target lesion
- Anticoagulation management plan (held or bridged per SIR guidelines)
- Patient allergy list
- Pre-procedure H&P or clinical note
- Pathology requisition forms (for biopsies)
- SIR complication thresholds for the planned procedure
Step 1: Pre-Procedure Safety Checks
Universal Protocol (Joint Commission)
| Step | Action | Verification |
|---|---|---|
| Correct patient | Two-identifier verification (name + DOB or MRN) | Verbal + wristband |
| Correct site | Mark laterality if applicable | Visible mark on patient |
| Correct procedure | Verify order matches planned procedure | Consent form matches |
| Time-out | Announce patient, procedure, site, laterality, allergies, antibiotics | All team members pause and confirm |
| Implant verification | N/A for most (verify if placing hardware) | — |
Coagulation Parameter Thresholds (SIR Consensus Guidelines 2019)
| Procedure Category | INR Threshold | Platelet Threshold | Anticoagulation Hold |
|---|---|---|---|
| Low bleeding risk (thoracentesis, paracentesis, superficial biopsy) | Correct if >2.0 | Correct if <20,000 | Hold per institutional protocol |
| Moderate bleeding risk (deep visceral biopsy, nephrostomy) | Correct if >1.5 | Correct if <50,000 | Hold warfarin 5 days; hold DOACs 48h |
| High bleeding risk (renal biopsy, transjugular liver biopsy) | Correct if >1.5 | Correct if <50,000 | Hold all anticoagulation; consider bridging |
Step 2: Procedure Documentation — Required Elements
Informed Consent Documentation
- Procedure name and purpose explained
- Risks discussed (bleeding, infection, pneumothorax, organ injury, non-diagnostic result)
- Alternatives discussed (surgical biopsy, observation, empiric treatment)
- Patient questions addressed
- Consent form signed, dated, and witnessed
Procedure Note Structure
Header:
- Patient identifiers, date, time, location
- Procedure name (CPT-level specificity)
- Performing physician and assistants
- Imaging guidance modality
- Anesthesia type
Indication:
- Clinical indication with relevant history
- Target lesion description (location, size, relationship to critical structures)
Technique (in chronological order):
- Patient positioning
- Pre-procedure imaging review and target localization
- Sterile preparation and draping description
- Local anesthesia (agent, concentration, volume, location)
- Sedation medications (if used) with doses and times
- Access approach (skin entry site, trajectory, distance to target)
- Needle/device type and gauge
- Number of passes
- Guidance method (real-time vs. intermittent; CT, US, fluoro)
- Specimens obtained (cores, aspirate, fluid) with descriptions
- Post-procedure imaging (pneumothorax check, hemorrhage assessment)
- Hemostasis method (manual pressure, gelatin plug, coil)
Step 3: Specimen Documentation
Biopsy Specimens
| Element | Documentation |
|---|---|
| Number of cores | e.g., "4 core specimens obtained" |
| Core length/quality | e.g., "each measuring approximately 1.5 cm, tan-white, firm" |
| Touch preparations | If performed, note number of slides |
| Specimen destination | Surgical pathology, microbiology, flow cytometry, cytogenetics |
| Rapid on-site evaluation | If ROSE performed, document adequacy assessment |
| Fixative | Formalin, saline, RPMI, specific culture media |
| Labeling | Verified patient identifiers on specimen container |
Fluid Specimens
| Element | Documentation |
|---|---|
| Volume | Total volume aspirated (mL) |
| Appearance | Color, clarity, consistency (serous, serosanguinous, purulent) |
| Tubes sent | Cell count (purple), protein/LDH/glucose (green), culture (sterile), cytology (dedicated container) |
| Fluid pocket | Pre- and post-drainage dimensions if applicable |
Step 4: Complication Documentation and SIR Thresholds
Immediate Complication Assessment
| Complication | Detection Method | Threshold for Concern |
|---|---|---|
| Pneumothorax | Post-procedure CXR or CT | Any new pneumothorax; chest tube if >2 cm or symptomatic |
| Hemorrhage | Post-procedure imaging + vital signs | Active extravasation, expanding hematoma, hemodynamic instability |
| Organ injury | Post-procedure imaging | Non-target organ puncture, bile leak, bowel perforation |
| Vasovagal | Vital signs monitoring | Bradycardia <50, hypotension; treat with atropine and fluids |
| Infection | Delayed (24–72h) | Fever, increasing pain, elevated WBC |
SIR Complication Thresholds (Selected Procedures)
| Procedure | Major Complication Threshold | Minor Complication Threshold |
|---|---|---|
| CT-guided lung biopsy | Pneumothorax requiring chest tube: <5% | Pneumothorax (any): <25% |
| CT-guided liver biopsy | Major hemorrhage: <2% | Minor hemorrhage: <5% |
| Abscess drainage | Sepsis: <5% | Catheter dislodgement: <10% |
| Paracentesis | Bowel perforation: <1% | Local hematoma: <5% |
| Image-guided musculoskeletal injection | Infection: <0.1% | Vasovagal: <5% |
Document all complications using the SIR classification: Minor (A = no therapy, B = nominal therapy) or Major (C = requiring hospitalization <48h, D = >48h or escalation, E = permanent adverse sequelae, F = death).
Step 5: Post-Procedure Care
Recovery Documentation
| Element | Detail |
|---|---|
| Vital signs | Baseline and at 15, 30, 60 min (minimum) |
| Post-procedure imaging | CXR for lung biopsy; CT check for abdominal procedures |
| Activity restrictions | Bed rest duration, weight-lifting restrictions, driving restrictions |
| Follow-up plan | When to expect pathology results; follow-up appointment |
| Discharge criteria | Stable vitals, no expanding hematoma, no respiratory distress |
| Patient instructions | Written discharge instructions with emergency contact information |
| Anticoagulation resumption | When to restart held medications |
Discharge Instruction Essentials
- Signs/symptoms requiring emergency evaluation (increasing pain, shortness of breath, fever, bleeding)
- Activity restrictions with duration
- Wound care instructions
- Contact numbers (radiology department, emergency line)
- Follow-up appointment and pathology result discussion plan
Checkpoint B: Post-Draft Alignment (Mandatory)
- Was the Universal Protocol (time-out) documented?
- Is the technique section detailed enough for another radiologist to reproduce the procedure?
- Are all specimens documented with destination, fixative, and labeling verification?
- Is post-procedure imaging documented with findings?
- Are complications (or absence thereof) explicitly documented?
Quality Audit
- Informed consent is documented and signed before the procedure
- Universal Protocol (time-out) is documented with all elements
- Pre-procedure labs are reviewed and within acceptable thresholds
- Imaging guidance modality is specified
- Local anesthesia and/or sedation are documented with agents and doses
- Needle/device type and gauge are specified
- Number of passes is documented
- All specimens are described and sent to correct destinations
- Post-procedure imaging is performed and findings documented
- Complications are documented (or "no immediate complications")
- Vital signs are monitored and documented in recovery
- Discharge criteria are met and documented
- Written discharge instructions are provided to the patient
- Anticoagulation resumption plan is documented
- Procedure meets SIR quality thresholds
Guidelines
- Never begin an image-guided procedure without verified informed consent and a completed Universal Protocol time-out.
- Document the technique in sufficient detail that another interventionalist could understand the approach, even if they were not present.
- Always perform post-procedure imaging for thoracic and deep abdominal biopsies — do not rely solely on clinical assessment for pneumothorax or hemorrhage.
- Use SIR consensus guidelines for coagulation management — individual institutional protocols may be more conservative, which is acceptable.
- Specimen labeling must be verified with two patient identifiers before leaving the procedure room.
- Document complications using SIR severity classification (Minor A/B, Major C/D/E/F) for quality-assurance tracking.
- For lung biopsies, position the patient biopsy-side-down after the procedure to reduce pneumothorax risk, and obtain post-procedure chest radiograph at 1–2 hours.