Documentation is of paramount importance in all aspects of medical practice, indeed many international governing medical bodies place accurate record keeping as one of the fundamental requirements for good clinical care.^{1 2} Accurate and concise documentation is not only a record of patient management, but also facilitates continuity of care, education and research, and has an important medicolegal role. Regional anaesthesia forms an integral part of modern anesthetic practice and with increasing evidence of benefits for acute and chronic pain management it is becoming ever more popular. Despite this rising popularity, there is a lack of international consensus regarding the minimum standards for its documentation. By contrast, there exist extensive international guidelines on documentation in general anaesthesia.³

Limited work has been done in this area previously at a national level in Ireland and the US, including the formation of a proposed standardized block note.^{4 5} More recently an international expert panel, jointly supported by ESRA and ASRA, sought to begin the process of standardizing regional anesthesia documentation by means of a Delphi consensus project.⁶ This latest research highlighted the complexities faced when attempting to standardize practices across jurisdictions and healthcare systems. The documentation requirements of all anesthesia providers vary significantly depending on their individual preferences, the medicolegal climate in which they practice and the requirement of documentation for renumeration purposes. The availability of electronic medical records also featured heavily in this work with respect to their potential to automate much of the routine documentation that is required for regional anaesthesia and thus reduce this burden for clinicians. These issues need to be considered when implementing this research into guidelines and individual practice.

This presentation will address the most recent research in documentation in regional anaesthesia and the challenges this may present to the clinician.

References

1. General Medical Council. Good Medical Practice. March, 2021. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice

2. Medical Board of Australia. Good medical practice: a code of conduct for doctors in Australia. March, 2021. https://www.medicalboard.gov.au/codes-guidelines-policies/code-of-conduct.aspx

3. Checketts MR, Alladi R, Ferguson K, et al. Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. Jan 2016;71(1):85–93. doi:10.1111/anae.13316

4. Moran PJ, Fennessy P, Johnson MZ. Establishing a new national standard for the documentation of regional anaesthesia in Ireland. BMJ Open Qual. 2017;6(2):e000210. doi:10.1136/bmjoq-2017-000210

5. Gerancher JC, Viscusi ER, Liguori GA, et al. Development of a standardized peripheral nerve block procedure note form. Reg Anesth Pain Med. 2005 Jan-Feb 2005;30(1):67–71. doi:10.1016/j.rapm.2004.11.001

6. Ahmed HM, Atterton BP, Crowe GG, et al. Recommendations for effective documentation in regional anesthesia: an expert panel Delphi consensus project. Reg Anesth Pain Med. May 2022;47(5):301–308. doi:10.1136/rapm-2021-103136