Figure 80-1. Anesthesia procedure note for peripheral nerve block.

Prior to this description, an example of a regional anesthesia procedure note could not be found in the literature. Starting almost 40 years ago, publications have described the development and evaluation of individual anesthesia records.^6–8,9 Authors have developed forms for documenting anesthetics with pooled expertise at a single practice^6–8 and multiple institutions.⁹ Most anesthesia forms in use today likely have elements derived from these forms or have formats and content developed in parallel many years ago. Common to most of these efforts is a lack of emphasis on the documentation of regional techniques. In surveys of anesthesia records, space or narrative details of regional anesthetics have been noted in only 2-30%.^10,12 This lack of emphasis on regional anesthesia leads to sparse documentation of these procedures. We do not really know how often regional anesthetics are well or are poorly documented, but we know in general that documentation of anesthesia is often lacking^13–19 and that many malpractice suits are difficult to defend because of inadequacies of the medical record.^16–20

Since the publication of the PNB form above, another similar form documenting the performance of neuraxial blockade has been devised (Figure 80–2).²¹ Both these forms were created using the expertise of many individuals at several institutions. Furthermore, both efforts shared the goal of providing documentation of sound clinical care in the format of a robust medicolegal, billing, and regulatory- compliant form. The authors of both forms used the literature to find support for including or excluding each proposed entry prior to compiling the form. If an entry was included it was believed to be a key element of clinical care, and legal, billing, or regulatory compliance. Neither of these documents will be ideal for every institution. When formulating a procedure note, keep the following five suggestions in mind:

Clinical Pearls

Guide the anesthesia practitioner to meet the standard of care in every interaction. Do so through the format of the form. Using Figure 80–1 as an example, the practitioner can simply check a box if he has performed an IV test with epinephrine, but must record the rationale when he does not. The practitioner must document corrective actions for untoward events such as encountering blood in the needle or pain or high pressure with injection.

Encourage efficiency while ensuring thoughtfulness. Anesthesiologists might be able to simply check boxes for routine aspects of procedures, but the form should also require written contributions for decisions that need individualization. For example in Figure 80–2, the anesthesiologist must fill in the drug choices and adjuvants for neuraxial blockade and record the parameters that elicit a motor response when using a nerve stimulator or paresthesia on completing the form in Figure 80–1.

Require documentation to safeguard against common medicolegal challenges.

For example, both figures are formatted to require the practitioner to characterize the patient’s state of consciousness, in part because current medicolegal disputes may center on the patient’s level of consciousness. Furthermore, although there is no evidence in the literature that level of consciousness has any relevance to the risk of nerve injury, such documentation may offer clues for future analysis of risk factors for nerve block-related complications. Figure 80–2 requires documentation of conformation of antithrombisis-anticoagulation status, in part for similar reasons.

Document compliance with initiatives adopted by regulatory agencies. Both Figure 80–1 and Figure 80–2 allow adequate space for patient identification, recognition of site and side of surgery, and acknowledge the importance of assessment of analgesia using pain scores. (Again, this is sound clinical judgment but also represents a good approach to regulatory compliance).

Facilitate successful and accurate billing. For example, both Figures 80-1 and 80-2 include boxes that should be checked to indicate that the surgeon has requested certain PNBs for postoperative pain management, and these blocks are clearly listed and named. 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.

Used at St. Lukes—Roosevelt Hospital for a number of years. Documentation at this institution incorporates numerical information on injection pressure (see Figure 80–3).²² This is a good example of individualization of documentation for the needs of a particular institution. The authors of this form collect data on injection pressure during PNBs. These authors are in the process of using data on injection pressure to create a database in which a correlation between injection pressures and neurapraxia is being sought.²³ The association between regional anesthesia practices and peripheral nerve injuries is a particularly complex and rapidly changing subject, with patient care as well as economic, legal, and public relations ramifications. Documentation of regional anesthesia procedures maybe especially helpful in improving our understanding of these associations. Furthermore, documentation is likely to provide the clinician with medicolegal protection. For example, the authors of Figure 80–3 note that although the practice of injection pressure monitoring has not yet become standard,⁷ objective monitoring and documentation of injection pressure may serve as strong medicolegal edvidence that the anesthesia provider avoided an injection force capable of injuring a fascicle (greater than 20 PSI) by using all available knowledge and technology to do so.²³ When neurologic complications do occur, these complications may be attributed to regional anesthesia procedures by patients, clinicians, hospital administrators, and lawyers in spite of the fact that surgery and positioning during surgery may be the principal and much more commonly encountered reasons for nerve deficit. Therefore, a lack of objective documentation of regional anesthesia may place pracitioners in a uniquely vulnerable position in cases of adverse neurologic outcome. Although this may be less of an issue for institutions where regional anesthesia has become established, it can present a significant obstacle to establishing regional anesthesia in others.

Figure 80-2. Anesthesia procedure note for neuraxial blockade.

Ideally, more widespread use of procedure forms to document regional anesthesia and the sound medical care that is part of the regional anesthetic, may even result in more widespread use of these procedures. Hopefully, this will occur when the forms we use result in easier documentation, more standardization of care, and better regulatory and medicolegal protection for the clinician, while at the same time giving the researcher a tool for collecting data to adapt our practices for the future.

Peripheral nerve injury with PNBs is a particularly complex and rapidly changing subject, with patient care, economic, legal and public relations ramifications. It is well accepted that neurologic complications are more commonly caused by an injury during surgery and involving positioning rather than resulting from the use of PNBs. However, because the nature of the nerve block procedure involves placing a needle in the vicinity of the nerves and plexuses, it is often assumed that a PNB procedure is a cause for any neurologic symptoms following surgery. The current lack of monitoring tools during PNBs and objective documentation of PNBs places regional anesthesia practitioners in a uniquely vulnerable position in cases of adverse neurologic outcome. Although this may be less of a problem in institutions with tradition of using regional anesthesia, it can present a significant obstacle in practices wishing to introduce PNB procedures. Adherence to the suggested PNB documentation coupled with more objective monitoring of various aspects of PNB procedure is likely to result in both a reduction of the risk of neurologic injury and a more widespread use of PNB procedures in clinical practice.

DOCUMENTATION OF INFORMED CONSENT

Informed consent is a process that consists of three steps: (1) disclosure of medical information, (2) patient understanding (or competency), and (3) mutual decision-making.²⁴ Documenting the adequacy of the informed consent process is difficult if not impossible for any medical treatment including regional anesthesia. However, using a written form to document the conduct of the informed consent process as it relates to regional anesthesia may have advantages for all three steps of the consent process. Furthermore written consent may have benefits beyond relying on verbal informed consent alone. First, a well-constructed informed consent form may guide the process by providing scripted information. For example, most state legislatures in the United States have upheld the idea that the disclosure of risk during the informed consent process should cover those risks that are common and those that are the most serious.²⁴ A document can be used to guide disclosure as a matter of routine. Disclosing information in this way has not been found to alarm patients.²⁵ Second, written consent has been shown to improve patient recall of risks and benefits, which may improve patient understanding of medical therapy.²⁵ Third, because regional anesthesia is often viewed as an optional therapy in addition to or beyond general anesthesia, patients’ and physicians’ medical decision making must incorporate a discussion of both benefits and risks. A written consent form that documents both may help establish that this process truly occurred. Such a form could in itself be viewed as a patient education document: When a physician reviews the form (Figure 80–4) with the patient, the document becomes an integral part of the informed consent process in addition to the documentation of the process.

All but one study of informed consent have focused on therapies besides regional anesthesia. Most studies^26–32 examining informed consent in medicine have centered on the issue of patient recall. Recall of information is, of course, not the same as understanding of the information, but it is the one objective measure of competency we have. These studies have generally demonstrated poor rates of recall. With verbal consent, recall has been found to be adversely effected by the style of presentation.³³ With written consent, recall has been found to depend on format of the form. Written consent has been found to be recalled best when the consent form is a brief one,³⁴ the patient is given an opportunity to discuss it with the anesthesiologist, and the patient is given a copy of the signed consent document.³⁵

Similarly to the two examples of regional anesthesia procedure notes, the example of an anesthesia risk disclosure form will not be ideal for each practice. For that reason, I recommend that the reader adapt the forms to his or her practice.

Clinical Pearls

When obtaining informed consent keep the following five suggestions in mind:

Be brief. Figure 80–4 uses a table type format to help avoid the appearance of a document with multiple paragraphs of text. Brevity enhances recall.

Include major and common risks but do so along with specific benefits or expected outcomes. If only risks are disclosed without discussion of benefits, the patient cannot make an informed decision. The patient will not understand why these risks should be undertaken.

Educate and document at the same time. Written as well as verbal discussion has been shown to best enhance recall of consent. Obtaining written consent without discussion is neither medically or legally valid.

Indicate both the common practices of the practitioner and the preferences of the patient. Figure 80–4 is geared to the practice of regional anesthesia, incorporating a check box system to indicate what has been discussed with each patient.