++
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
++
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.
++
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
++++
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
++
Since the publication of the PNB form above, another similar form
documenting the performance ...