The author, JC Gerancher MD discusses the principals that add value to an electronic (EHR) or paper regional anesthesia note. See also: http://www.raadvantages.com/wp-content/uploads/Helping-Patients-Understand.pdf

1. Building a Better Regional Anesthesia Procedure Note
J.C. Gerancher, MD, Winston-Salem, N.C.
July, 2005
In many facilities, practitioners do not place enough emphasis
on documenting regional anesthesia procedures in the
medical record. As a result, they can expose themselves to
malpractice risk, jeopardize payment and, most importantly,
miss opportunities to guide good patient care. The good news
is that it is easy to build a better procedure note for your
institution that will likely help you deliver excellent care,
provide legal protection, and maximize billing success.
You can begin by visiting a website I designed, www.allnumbedup.com. If you click on
“Regional Anesthesia and Acute Pain Management Forms,” you will find free
templates for three types of regional anesthesia procedure notes: one for peripheral
nerve blocks, one for neuraxial blocks, and a third for combined regional anesthesia
blocks. Some were written by multiple authors at several institutions, and all are in
pdf format.
I recommend customizing your forms to suit your needs. While doing so, keep these
goals in mind. The form should:
Encourage efficiency while ensuring thoughtfulness. Anesthesiologists can
check boxes for routine aspects of procedures, but the form should also require
written contributions for decisions that need individualization. For example, on our
procedure notes, the anesthesiologist must fill in the drug concentration and
volume for each injection and, when using a nerve stimulator, record the
parameters that elicit a motor response or paresthesia.
Guide the anesthesiologist to meet the standard of care in every case. On
our forms, for example, the anesthesiologist can simply check a box if he has
performed an IV test with epinephrine, but he must record the rationale when he
does not.
Require the anesthesiologist to characterize the patient's state of
consciousness. Currently, many medico-legal disputes appear to center on the
patient's level of sedation. A medical record that documents this crisply will protect
practitioners and the facility from certain legal challenges that could arise when
this is not documented.
Require the anesthesiologist to document how he responds to clinical
variations. For example, our form requires the anesthesiologist to record actions
taken when injection creates a pressure rise or paresthesia, and/or when
aspiration of blood is encountered.
Facilitate successful and accurate billing. Precise documentation will help
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2. ensure proper reimbursement. For example, the record should show that the
surgeon has requested certain peripheral nerve blocks for post-op pain
management. Without this documentation, the insurer may be less likely to
reimburse. The procedure note should also ensure that an anesthesiologist
medically directs each block, which is important in a residency or other training
program. We simply attach our forms to our reimbursement requests, and this
obviates the need for our coders/billers to “hunt and peck” through incomplete,
illegible records.
I hope our regional anesthesia forms and the advice in this column will help you
establish your own winning documentation strategy. Best of luck!
Dr. Gerancher is Associate Professor and Head of the Regional Anesthesia and Acute
Pain Management Section at Wake Forest University School of Medicine, Winston-
Salem, North Carolina. University School of Medicine and Section Head of Regional
Anesthesia and Acute Pain Management in Winston-Salem, N.C.
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