Regional Anesthesia Catheter Follow-Up Note

Date/Time: [date and time]

Encounter Type: [inpatient rounds / telephone follow-up]

POD: [postoperative day]

Catheter Day: [catheter day number]

Block Type/Location: [block name and anatomical location]

Laterality: [left / right / bilateral]

Procedure/Surgery: [procedure name]

Catheter/Infusion Summary

Local anesthetic: [agent and concentration]; Delivery mode: [continuous / continuous + patient-controlled bolus]; Basal rate: [mL/hr]; Bolus/lockout: [bolus mL, lockout min / N/A]; Pump status: [running / paused / empty / alarm]; Source: [direct pump check / per chart / per nursing]; Concomitant analgesia: [non-opioid adjuncts]; Opioids (~24h OME): [amount]

Subjective

[Overall pain control summary sentence]

Pain scores: Rest [0–10]; Movement [0–10]. Pain location: [anatomic areas]; [matches / partially matches / does not match expected block coverage]. Breakthrough: [frequency, triggers, response to interventions]. Function: [PT participation, ambulation, sleep]. (For telephone follow-up, explicitly label all findings as patient-reported.)

Sensory/motor symptoms: [numbness distribution, subjective weakness, functional limitations such as knee buckling or grip weakness] (Include only if reported.)

Adverse effects screen:

• LAST-type: [Denies / Reports: tinnitus, metallic taste, perioral numbness, dizziness, confusion]
• Respiratory: [Denies / Reports: dyspnea, chest tightness] (if relevant to block type)
• Infection: [Denies / Reports: fever, increasing redness, drainage, worsening tenderness]
• Bleeding/hematoma: [Denies / Reports: new swelling, firmness, new neurologic change]

Objective

(For telephone follow-up, state: "Telephone follow-up—physical exam not performed" and omit exam fields.)

Vitals: [relevant vitals or refer to nursing flowsheet]

Insertion site: [dressing status]; [erythema]; [tenderness]; [drainage]; [catheter marking/depth]; [leakage]

Sensory exam: [distribution findings]

Motor exam: [key muscle groups with strength]; Fall risk: [elevated / not elevated] (for lower extremity blocks)

Anticoagulation: [agent(s), last dose date/time] (Include if deep plexus site, removal planned, or regimen change; if unknown, state unknown and note verification plan.)

Assessment

Pain control/coverage: [efficacy summary; whether catheter coverage matches expected distribution]

Block effects: [sensory/motor block adequacy vs excess; explicit fall-risk statement for LE blocks]

Site status: [dressing integrity, signs of infection or catheter migration]

Complications: [No current concern / Concern for infection, bleeding/hematoma, LAST, or atypical neurologic deficit with next steps] (State absence of concern only if supported by exam or explicit patient report.)

Plan

• Catheter disposition: [continue unchanged / adjust settings (old → new with goal) / pause / remove today / schedule removal with timing criteria]
• Multimodal analgesia: [continue / adjust / add / hold specific agents] (Include only if changes made.)
• Safety/monitoring: [fall precautions, mobility guidance, escalation triggers, next follow-up timing]
• Communication: [who notified and key information conveyed]
• If catheter removed: [time, personnel, site condition, tip intact, hemostasis, post-removal analgesia, anticoagulation coordination] (Include only if removal performed this encounter.)
• Outpatient/discharge catheter: [instructions reviewed, emergency contact pathway confirmed] (Include only if applicable.)