Occipital Nerve Block Procedure Note

Date/Time of Procedure: [Date and time of procedure]

Location: [clinic / ED / procedure suite / bedside / other]

Performing Clinician: [Name, credentials]

Patient Position: [seated / prone / supine], [neck flexed / neck neutral]

Procedure Identification

Procedure(s) Performed: [Greater Occipital Nerve Block / Lesser Occipital Nerve Block / Third Occipital Nerve Block] (Select all that apply.)

Laterality: [Right / Left / Bilateral] (Must be explicitly stated; do not infer from diagnosis or pain location.)

Guidance Method: [landmark-based / ultrasound-guided]

Indication and Pre-Procedure Assessment

Indication/Diagnosis: [occipital neuralgia / migraine / cervicogenic headache / cluster headache / other specified]

Baseline Pain Score (0–10): [Numeric value 0–10 / Pain score not obtained]

Prior Occipital Nerve Blocks: [None / Brief summary of prior blocks including dates, response, and complications] (Include only if relevant.)

Contraindication Screening:

• Allergy to intended agents: [present / absent]
• Local infection at injection site: [present / absent]
• Anticoagulant/antiplatelet use: [none / agent(s) and last dose]
• Coagulopathy history: [present / absent]

(A summary statement such as "Contraindication screen reviewed; no contraindications identified" is acceptable if all items were reviewed.)

Informed Consent

Consenting Party: [patient / surrogate (relationship)]

Discussion: Nature of procedure, risks, benefits, and alternatives discussed; questions answered; patient agreed to proceed.

Risks Discussed: [pain, bleeding/hematoma, infection, vascular puncture, vasovagal episode, transient numbness, allergic reaction, nerve injury, steroid-related risks] (Include steroid-specific risks only if steroid used.)

Consent Type: [written / verbal per site policy]

Time-Out and Site Verification

Time-Out: Performed immediately prior to procedure.

Verification: Correct patient identity, correct procedure, and correct site/side confirmed.

Site Marking: [performed / not required per policy]

Technique

Skin Antisepsis: [prep agent used, e.g., chlorhexidine or povidone-iodine]

Needle: [gauge]-gauge, [length]

Per-Site Technical Details: (Repeat for each nerve and each side injected.)

• Nerve & Side: [GON / LON / TON] – [Right / Left]
• Landmarks: [occipital protuberance / mastoid process / superior nuchal line / point of maximal tenderness / other] (If landmark-based.)
• Insertion Site & Approach: [location relative to landmarks]; [needle path and depth]
• Aspiration Prior to Injection: [negative for blood / blood aspirated—Loss of Resistance confirmed prior to injection]
• Injection Pattern: [single deposit / fan-like distribution]
• Hemostasis: [manual pressure applied / not required]

(If ultrasound-guided, also document:)

• Structures Identified: [target nerve, occipital artery, adjacent tissues]
• Needle Visualization: [in-plane / out-of-plane]
• Spread Visualized Around Target: [yes / no]
• Image Archiving: [images saved to PACS/EHR / not archived]

Injectate

(Complete documentation required with no blanks. Document each nerve and side separately. If any detail was not recorded, explicitly note the documentation gap.)

• [Right / Left] GON: [Local anesthetic name] [concentration], [volume mL] + [Steroid name] [concentration], [dose mg]; Total: [mL]
• [Right / Left] LON: [Local anesthetic name] [concentration], [volume mL] + [Steroid name] [concentration], [dose mg]; Total: [mL]
• [Right / Left] TON: [Local anesthetic name] [concentration], [volume mL] + [Steroid name] [concentration], [dose mg]; Total: [mL]

(Include only nerves/sides that were injected; omit lines for nerves not treated.)

Total Volume (All Sites): [sum mL]

Mixture Details: [components and ratio / not applicable]

Lot Numbers/Expirations: [per facility policy / not required]

Immediate Outcome

Patient Tolerance: [well tolerated / poorly tolerated—symptoms]

Cutaneous Anesthesia in Expected Distribution: [achieved / not achieved / not assessed]

Pain Scores: Pre: [x]/10; Post ([time]): [y]/10 (If not obtained, state "Pain score not obtained.")

Observation Period: [duration]; patient [stable / required intervention] (If response not assessed, state: "Response to be assessed at follow-up; no immediate complications observed.")

Complications

Immediate Complications: [No immediate complications / bleeding / hematoma / vascular puncture / vasovagal episode / allergic reaction / neurologic symptoms / local anesthetic systemic toxicity concern / other]

Interventions: [None required / Intervention and outcome] (Include only if complications occurred.)

Follow-Up

Plan: [Return to clinic/service] in [timeframe]

Repeat Block: [planned if beneficial / consider based on response / not planned]

Discharge Instructions: [written / verbal / both] provided; patient [verbalized understanding / declined written—verbal provided]