Patient Identification

Acute Pain Management Service

NERVE BLOCK PROCEDURE NOTE

Date: _____________________ Start Time: ________________ am pm End Time: ________________ am pm

PROCEDURE: G Left G Right G Interscalene G Supraclavicular G Infraclavicular G Axillary G Femoral G Psoas (Lumbar Plexus) G Sciatic G Popliteal G Saphenous G Paravertebral_______level G Intercostal _______level G Retrobulbar G OTHER_________________________________________ CONSENT OBTAINED: G Verbal G Written Risk and Benefits discussed with G patient or G Family ____________________________________________________

TIME OUT: Date _________ Time _________ Printed Name ______________ Signature _____________________

1. Patient Identification Confirmed G Yes G No 3. Consent Checked G Yes G No

2. Lateral Checked G Yes G No 4. Marked Surgical Site G Yes G No INDICATION(s):G Refractory to pain meds G Post op analgesia G Surgeon request G Patient request G Surgical anesthesia G Other____________________________________________________________________

PREPG Chlorhexidine G Betadine G Sterile drape G Other___________________________________________

SEDATION MONITORSG Midazolam ____ mg G Fentanyl ___mcg G Propofol ____ mg G None G SpO2 G EKG G NIBP

TECHNIQUE: G Stimulation G Ultrasound guidance G TransarterialNeedle: G Stimuplex G Echogenic G RegularG 17 ga G 18 ga G 21 ga G 22 ga G 23 ga G 25 ga G 50 mm G 90 mm G 100 mm G Tuohy Landmarks: _____________________________________________________________________________Muscle groups stimulated _______________________________, Beginning Stim ________mA, End Stim ________mA, Depth:________ cm, Twitch ablated with ________mlCatheter: G 19 ga stimuplex G 20 ga non stim Final Catheter depth _________cm Catheter stim ________mA

AGENTS ADMINISTERED: Total volume administered___________mlG 1% G 1.5% G 2% G 3% G mepivacaine _____ml G lidocaine _____ml G chloroprocaine _____ ml G other _________________________________________G 0.2% G 0.25% G 0.375% G 0.5% G ropivacaine _____ml G bupivacaine _____ml G _____mg tetracaine Epinephrine: G 1:200,000 G 1:400,000 G none

COMPLICATIONS: Blood aspiration: + - Paresthesia + - resolved 3 ml test dose + - None

COMMENTS: ______________________________________________________________________________________________________________________________________________________________________________________

Resident Signature: ______________________________________ Date: _______________ Time: _______________

Attending Signature: _____________________________________ Date: _______________ Time: _______________

MR Form H3536-101-RR 10/10