Building a Better Regional Anesthesia Note (on paper or in an EHR)
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The document emphasizes the importance of thorough documentation in regional anesthesia procedures to minimize malpractice risk and enhance patient care. It provides resources, including customizable templates for procedure notes, while highlighting essential documentation practices that ensure compliance with standards of care and facilitate accurate billing. The author, Dr. Gerancher, advocates for creating efficient forms that require necessary written details to protect practitioners and support reimbursement efforts.
Building a Better Regional Anesthesia Note (on paper or in an EHR)
- 1. Building a Better Regional Anesthesia Procedure Note J.C. Gerancher, MD, Winston-Salem, N.C. 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 Latest Articles Total Joints at a Freestanding ASC? Why Not? Read part 58 Are Nerve Stimulators Obsolete? Read part 57 Nerve Stimulation with Ultrasound: The Clinical Benefits Read part 56 Article Listing TAP: A New Standard for Abdominal Surgery? Is <0.2mA a reliable indicator of intraneural injection? 5 Top Tips for Block Reimbursement A Breakthrough in Nerve Stimulation A Two-Pronged Approach to PONV Prevention Get Total Knee Patients Moving With Continuous Nerve Blocks Nerve Blocks: The Right Choice in a Down Economy Nerve Blocks: A Hospital CEO's Perspective Paravertebral Blocks: Benefits Beyond Expectations Blocks Help Hernia Patients Go Home Faster Intra-Articular Infusions or Nerve Blocks? Continuous Nerve Blocks Boost Patient Confidence Yes You Can Get Reimbursed for Nerve Blocks Peripheral Nerve Blocks: A Wise Investment A Surgeon's View: Dispelling Some Common PNB Myths A Surgeon's Perspective: The Power of PNBs Acute Pain Nurse: Key to Continuous Infusion Success A Breakthrough in Nerve Stimulation
- 2. 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. Brought to you as an educational service by No Pain, Big Gain Our Insurers Pay for Peripheral Nerve Blocks Fortifying Our Future With PNB Training Stimulating Catheters for Outpatient Surgery When Should We Use Stimulating Catheters? What Is Ultrasound's Role in Peripheral Nerve Blocks? There's No Better Advertisement than a Happy Patient! Avoiding Post-Lithotripsy Pain Regional Anesthesia Took My Pain From 10 to 0 How to Make Peripheral Nerve Blocks Even Safer Helping Patients Understand Regional Blocks Ultrasound and Nerve Stimulation: Perfect Together The Post-Opioid Era Practical Pain Control In Our PACU, Blocks Made Miles of Difference Filling the Analgesic Gap Is Regional Anesthesia More Cost-Efficient? Prime Patients Early for PNB Success With Nerve Blocks, Time is Safety Nerve Blocks Improve Patient Well-Being The PNBs Have It Continuous Peripheral Nerve Blocks: The Jury Is In Is Regional Anesthesia More Cost-Efficient? Block On! Regional Anesthesia: Lessons from Iraq Help is On the Way The Promise of Pediatric Peripheral Nerve Blocks Building a Better Regional Anesthesia Procedure Note Perception is Everything Peripheral Nerve Stimulators Improve Patient Comfort Regional Anesthesia Helps Elderly Patients Stay Alert and On Track 4 Ways to Make Continuous Infusions Run More Smoothly
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