Background and Aims No standards exist for documentation of peripheral nerve blocks (PNBs). Aim: To identify what clinicians think should be essential documentation and evaluate whether current practice meets these standards.
Methods Anaesthetists from three hospitals were surveyed. Forty suggested documentation topics were listed. We asked what they thought should be essential documentation and what they were currently documenting.
We performed a retrospective audit across two hospitals, looking at which of the forty topics had been documented for all PNBs. In the hospital using handwritten notes, anaesthetic charts were audited over two-weeks, and in the hospital using a computerised programme, notes were audited over 15-months.
Results 41 anaesthetists were surveyed. 12 documentation topics were thought to be essential by over 80%. Documentation of 38 PNBs were audited in the hospital using handwritten notes, and 960 PNBs in the hospital using computerised records.
Conclusions We found a discrepancy between perceived and actual documentation. Computerised systems improve this but are reliant on programming, demonstrated as only one percent of notes documented complications because no text field prompted this. Clear guidelines are required so that documentation of PNBs can be standardised.
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