Peripheral Nerve Block Procedure Note (Chronic Pain)

Date/Time: [Procedure date and start–end time]

Location: [clinic / ASC / hospital outpatient / bedside]

Operator: [Primary proceduralist name and credentials; assistants if applicable]

Procedure: [Laterality] [target nerve(s)] block under [guidance modality] (Laterality must be explicitly stated. If laterality is not documented, insert [REQUIRES CLARIFICATION: laterality].)

Indication

• [Referring condition or suspected pain generator]
• [Targeted pain distribution and rationale for nerve selection]
• [Laterality rationale based on symptoms, exam, or imaging]
• [Intended use: diagnostic / therapeutic / staged diagnostic-to-therapeutic] (If diagnostic, note that short-acting anesthetic response will confirm pain source.)
• [Prior treatment context: conservative therapies, prior injections and response, relevant imaging]
• [Sedation intentionally avoided to preserve diagnostic validity: yes / N/A] (Include for diagnostic or staged blocks.)

Pre-Procedure Assessment

• Baseline pain: [0–10] with [key functional limitation]
• Provoking activity for diagnostic retest: [specific activity and baseline pain during activity] (Include for diagnostic or staged blocks.)
• Focused neurologic exam: [sensation / motor / reflexes relevant to target nerve]
• Allergies reviewed: [local anesthetics / steroids / latex / chlorhexidine – presence/absence and specifics]
• Anticoagulation status: [agent(s), last dose; acceptable to proceed: yes / no]
• Injection site: [no local infection / findings]
• Vital signs: [BP / HR / RR / SpO2]

(If any required element is unavailable, document a reasoned exception rather than "N/A".)

Consent and Time-Out

Informed consent obtained on [date/time]; patient demonstrated decision-making capacity. Risks discussed included bleeding, infection, nerve injury, intravascular injection, local anesthetic systemic toxicity, and allergic reaction [plus steroid-specific risks if steroid used] [plus radiation exposure if fluoroscopy used]. Benefits and alternatives were discussed; questions answered.

Time-out performed immediately prior to procedure confirming correct patient, procedure, site/laterality, allergies, and equipment readiness.

Procedure Details

• Positioning: [supine / prone / lateral decubitus / seated; limb/head position as relevant]
• Skin prep and sterility: [prep agent], [sterile technique elements: mask, cap, sterile gloves, sterile probe cover if applicable]
• Guidance modality: [ultrasound / fluoroscopy / landmark]
  • Ultrasound: [transducer type/frequency], sterile cover used, [key structures visualized], [in-plane / out-of-plane] approach, real-time visualization of needle tip and injectate spread confirmed
  • Fluoroscopy: [views obtained], [contrast pattern if used], radiation safety measures observed
  • Landmark: [anatomic landmarks used], [rationale for not using imaging]
• Needle: [type], [gauge], [length]
• Aspiration: [negative / positive – describe]; incremental injection with frequent aspiration performed
• Patient symptoms during injection: [pressure / paresthesia / pain / none; action taken if atypical]
• Distribution confirmed: [clinical and/or imaging confirmation of spread to target]
• Hemostasis/dressing: [applied pressure / bandage / none required]

Injectate

(Document per nerve and per side. Laterality must be explicit. If any detail is missing, insert [REQUIRES CLARIFICATION: injectate details].)

• [Right/Left] [nerve]: [local anesthetic name] [concentration] [volume mL] [± epinephrine], [steroid type/dose if used (particulate/non-particulate)], [diluent if used]; total [X] mL
• (Add lines for each nerve/side. Remove unused template lines.)

Immediate Post-Procedure

• Post-procedure vitals: [BP / HR / RR / SpO2]
• Focused neurologic check: [motor function / sensation in target distribution]
• Immediate adverse effects: [none / describe]
• Pain scores: pre = [0–10] at [time]; immediate post = [0–10] at [time]; patient-reported percent relief: [X%]
• Diagnostic retest: [provoking activity repeated – percent relief and functional change] (Note confounders if present: sedation, unexpected spread, concurrent procedures.)

Complications: [none / describe complication and management] (Always include; default to "none" if no issues.)

Disposition and Follow-Up Plan

Patient tolerated the procedure [well / with issues – describe]. Discharged in [stable] condition.

• Expected effects: [anticipated duration of numbness/weakness based on anesthetic used]
• Safety precautions: [no driving until sensation/strength return / fall risk / limb protection]
• Red flags reviewed: progressive weakness or numbness, dyspnea, severe dizziness, allergic reaction signs, expanding hematoma – seek urgent evaluation

For Diagnostic Blocks

• Positive response criteria: ≥[X]% pain relief with functional improvement for expected anesthetic duration
• Pain diary: record scores and ability to perform provoking activity at [30 min / 1 hr / 2 hr / 4 hr / bedtime / next morning]
• Follow-up: [telehealth / phone / in-person] at [timeframe]
• If/Then: If ≥[threshold]% relief with functional improvement for expected duration → [confirmatory block / definitive therapy]. If <[threshold]% or inconsistent → reassess diagnosis.

For Therapeutic Blocks

• Outcome tracking: [duration of relief], [functional gains], [analgesic changes]
• Next steps: [repeat injection interval if effective], [escalation to ablation or alternative if insufficient]
• Follow-up: [timeframe and method]

Sedation

(Include only if sedation administered; otherwise omit entire section.)

• Sedation level: [minimal / moderate]
• Agents: [drug, dose, route, time]
• Monitoring: [continuous pulse oximetry, BP intervals, ECG if applicable]; airway equipment available
• Discharge criteria: [Aldrete or equivalent met], escorted home: [yes / no]