July, 2005

In many facilities, practitioners do not place enough emphasis on documenting regional anesthesia procedures in the medical record. As a result, they can expose themselves to malpractice risk, jeopardize payment and, most importantly, miss opportunities to guide good patient care. The good news is that it is easy to build a better procedure note for your institution that will likely help you deliver excellent care, provide legal protection, and maximize billing success.

You can begin by visiting a website I designed, www.allnumbedup.com. If you click on ???Regional Anesthesia and Acute Pain Management Forms,??? you will find free templates for three types of regional anesthesia procedure notes: one for peripheral nerve blocks, one for neuraxial blocks, and a third for combined regional anesthesia blocks. Some were written by multiple authors at several institutions, and all are in pdf format.

I recommend customizing your forms to suit your needs. While doing so, keep these goals in mind. The form should:

• Encourage efficiency while ensuring thoughtfulness. Anesthesiologists can check boxes for routine aspects of procedures, but the form should also require written contributions for decisions that need individualization. For example, on our procedure notes, the anesthesiologist must fill in the drug concentration and volume for each injection and, when using a nerve stimulator, record the parameters that elicit a motor response or paresthesia.
• Guide the anesthesiologist to meet the standard of care in every case. On our forms, for example, the anesthesiologist can simply check a box if he has performed an IV test with epinephrine, but he must record the rationale when he does not.
• Require the anesthesiologist to characterize the patient's state of consciousness. Currently, many medico-legal disputes appear to center on the patient's level of sedation. A medical record that documents this crisply will protect practitioners and the facility from certain legal challenges that could arise when this is not documented.
• Require the anesthesiologist to document how he responds to clinical variations. For example, our form requires the anesthesiologist to record actions taken when injection creates a pressure rise or paresthesia, and/or when aspiration of blood is encountered.
• Facilitate successful and accurate billing. Precise documentation will help ensure proper reimbursement. For example, the record should show that the surgeon has requested certain peripheral nerve blocks for post-op pain management. 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. We simply attach our forms to our reimbursement requests, and this obviates the need for our coders/billers to ???hunt and peck??? through incomplete, illegible records.

I hope our regional anesthesia forms and the advice in this column will help you establish your own winning documentation strategy. Best of luck!

Dr. Gerancher is Associate Professor and Head of the Regional Anesthesia and Acute Pain Management Section at Wake Forest University School of Medicine, Winston-Salem, North Carolina. University School of Medicine and Section Head of Regional Anesthesia and Acute Pain Management in Winston-Salem, N.C.