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Regional anesthesia practices are expanding and multiple techniques and approaches, with increasingly sophisticated equipment and medications, are currently being utilized. Automated1–3 and hand-held computerized4,5 medical record documentation for anesthetics are being developed, promoted, and instituted. These changes are occurring in a climate where documentation must meet the burden of legal, billing, and regulatory compliance. At present, basic standards for the documentation of regional anesthesia procedures (even those for the established paper-based anesthesia record) are lacking. Most formats for documentation of our anesthesia practices have evolved largely out of our practices for delivery of general anesthesia.6

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In short, the demands for documentation of regional anesthesia are growing while the utility of our traditional approaches become less adequate. The first goal of this chapter is to provide the reader with two newly designed templates to guide documentation of the performance of regional anesthesia procedures and to review the very limited literature on established paper- or computer-based records in this area. The second goal is to scrutinize documentation of the consent process for regional anesthesia and provide a similar example of a comprehensive consent form.

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Recently, collective expertise of individuals from several North American academic institutions was pooled to create a peripheral nerve block (PNB) form.7 The form represents a consensus reached by the authors and is based on available evidence in the literature, each of the author's knowledge of clinical practice, development of their own equipment and practices, medicolegal considerations, familiarity with billing and regulatory compliance, and experience with development of PNB procedure notes at their home institutions (Figure 80–1).7

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Fig. 80-1
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Anesthesia procedure note for peripheral nerve block.

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Prior to this description, an example of a regional anesthesia procedure note could not be found in the literature. Starting almost 40 years ago, publications have described the development and evaluation of individual anesthesia records.6,8,9 Authors have developed forms for documenting anesthetics with pooled expertise at a single practice6,8 and multiple institutions.9 Most anesthesia forms in use today likely have elements derived from these forms or have formats and content developed in parallel many years ago. Common to most of these efforts is a lack of emphasis on the documentation of regional techniques. In surveys of anesthesia records, space or narrative details of regional anesthetics have been noted in only 2–30%.10–12 This lack of emphasis on regional anesthesia leads to sparse documentation of these procedures. We do not really know how often regional anesthetics are well or are poorly documented, but we know in general that documentation of anesthesia is often lacking13–19 and that many malpractice suits are difficult to defend because of inadequacies of the medical record.16,20

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Since the publication of the PNB form above, another similar form ...

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