5/1/13 – Key Documentation Elements for Peripheral Nerve Blocks

Question: What are the key items we should be documenting when placing a regional peripheral nerve block for post-op pain?

 

Answer: The following items should be included in your documentation for the block placement:

 

– Name of block performed

– Approach used

– Patient condition

– Indications for block

– Patient position

– Needle design, technique, and depth of insertion

– Local anesthetic used

– Dose

– Monitoring/narrative of event/description of motor response

– Patient vital signs following procedure

 

Blocks may be billed in addition to the anesthesia when the following two                           conditions apply:

 

– The anesthesia for the surgical procedure is not dependent on the efficacy of the regional anesthetic technique

– Time spent on perioperative placement of the block must be separated and not included in the reported anesthesia time

 


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