Peripheral Nerve Block Procedure Note

Date and time of procedure: [Date and time]

Patient name: [Full name]   DOB: [DOB]   MRN: [MRN]

Location: [Pre-op / OR / PACU / Floor / Clinic]

Service: [Anesthesiology / Acute Pain Service / Other]

Procedure performed: [Specific block name]

Laterality: [Right / Left / Bilateral / Unknown with explanation] (This field must not be left blank.)

Performing clinician: [Name, credentials]

Indication

[Clinical indication, surgical procedure and site if applicable, rationale for block selection, single-shot or continuous catheter planned] (Keep to 2-4 concise lines.)

Consent

• Consent status: [Written / Verbal / Implied-emergency]
• Consenting party: [Patient / Surrogate with relationship]
• Discussion: [Risks, benefits, and alternatives discussed; questions answered; block-specific risks noted]
• Timing relative to sedation: [Prior to sedation / After sedation with capacity confirmed / Not applicable]

Pre-Procedure Assessment

• Baseline neurologic status in block distribution: [Grossly intact / Pre-existing deficits described / Not assessed with reason] (Do not infer normal if not examined.)
• Anticoagulation/antiplatelet status: [Agent(s), last dose timing / None / Unknown with mitigation steps noted]
• Relevant allergies: [Local anesthetics / Chlorhexidine / Other / None reported]
• Infection concerns: [Present with details / Absent / Not assessed with reason]

Pre-Procedure Verification

(This section is mandatory and cannot be omitted.)

• Correct patient, procedure, and site verified: [Yes]
• Site marking: [Performed / Not feasible with reason]
• Time-out: [Completed immediately prior to needle insertion; laterality confirmed aloud]
• Team members present: [Names or roles]

Monitoring and Positioning

• Monitors: [NIBP / ECG / SpO2 / EtCO2 as applicable]
• IV access: [Established / Not established with rationale]
• Oxygen: [None / Nasal cannula with flow / Face mask with flow]
• Position: [Supine / Lateral / Prone / Sitting / Other]
• Skin preparation: [Solution and concentration]
• Sedation/analgesia: [None / Agent, dose, route, and patient responsiveness]

Block Technique

(If multiple blocks performed, repeat this section for each with separate laterality and medication documentation.)

• Block name and approach: [Block name, approach]
• Laterality: [Right / Left / Bilateral] (Repeat from header.)
• Target: [Nerve, plexus, or fascial plane]
• Number of attempts: [Number]
• Guidance modality: [Ultrasound / Nerve stimulation / Landmark / Combination] (Document details for modality used below.)
• Guidance details: [For ultrasound: needle approach, key structures identified, images archived. For nerve stimulation: motor response, threshold current. For landmark: rationale.]
• Equipment: [Needle type, gauge, length]
• Local anesthetic: [Drug name, concentration, volume in mL, total dose in mg]
• Additional local anesthetic: [Drug name, concentration, volume, dose] (If applicable.)
• Adjuvants: [Agent and dose / None]
• Test dose: [Composition and response] (If used.)
• Cumulative local anesthetic dose: [Total mg] (If multiple blocks performed.)
• Injection technique: Negative aspiration [Yes / No]; Incremental injection [Yes / No]; Patient symptoms [None / Paresthesia / Pain with details]; Injection resistance [None / Increased with actions taken]
• Technique narrative: [Brief 3-5 sentence description of needle path, spread of local anesthetic, and endpoint]

Catheter Details

(Include only if perineural catheter placed or attempted.)

• Catheter placement: [Successful / Unsuccessful with reason and subsequent management]
• Catheter depth at skin: [Depth in cm]
• Confirmation method: [Ultrasound visualization of spread / Negative aspiration / Stimulating catheter response]
• Securement and dressing: [Securement method, dressing type]
• Infusion orders: [Solution, concentration, basal rate, bolus parameters if patient-controlled]
• Responsible service: [Service for catheter management]
• Removal plan: [Timing, anticoagulation coordination if applicable]

Post-Block Assessment

• Patient tolerance: [Tolerated well / Discomfort with description]
• Block effect: [Sensory changes in expected distribution, motor effect observed] (If assessment limited by timing, document findings and reassessment plan.)
• Hemodynamic/respiratory status: [Stable / Changes with description]
• Surrogate evidence: [Ultrasound spread pattern or other evidence] (If formal testing not possible.)

Complications

(This section is required and must not be omitted.)

[None observed / Complication(s) with management and outcome]

Post-Procedure Plan

• Expected block duration: [Range with acknowledgment of variability]
• Limb protection: [Avoid temperature extremes, protect insensate limb]
• Fall precautions: [In place / Not applicable]
• Warning signs to report: [Signs of local anesthetic toxicity, progressive weakness, infection, catheter issues as relevant]
• Multimodal analgesia integration: [How block fits into overall pain management plan]
• Follow-up: [Timing and responsible service]

(Safety-critical fields—laterality, drug/dose, consent status, time-out, and complications—must be explicitly documented. If missing from dictation, insert placeholder such as "Not documented" rather than leaving blank.)