Paracentesis Safety Survey Form
Please complete this survey to help us assess safety and quality for your recent paracentesis procedure. Your feedback is valuable for improving care and safety.
Full Name
*
First Name
Last Name
Your Role
*
Patient
Healthcare Provider
Family Member
Other
Date of Paracentesis Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email (for follow-up if needed)
example@example.com
Were all safety checks performed before the procedure?
*
Yes, all safety checks were completed
Some safety checks were missed
No safety checks were performed
Not sure
Were any of the following medications taken prior to the procedure? (Select all that apply)
Anticoagulants (e.g., warfarin, heparin)
Antiplatelet agents (e.g., aspirin, clopidogrel)
No relevant medications
Not sure
Other
Were there any symptoms or complications after the procedure?
No symptoms or complications
Pain at procedure site
Bleeding or bruising
Fever or chills
Dizziness or weakness
Other
Was ultrasound guidance used for the procedure?
*
Yes
No
Not sure
Were there any barriers or challenges to performing the procedure safely?
No barriers or challenges
Equipment issues
Staffing or communication issues
Patient-related factors
Other
Additional comments or concerns
Submit Survey
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