What information should be included in epidural procedure notes?

Essential Components of Epidural Procedure Notes

Comprehensive documentation of epidural procedures must include specific patient, technical, and monitoring details to ensure patient safety and quality care.

Patient Information and Pre-Procedure Documentation

• Patient identification information (name, date of birth, medical record number)
• Date and time of procedure
• Indication for epidural placement
• Informed consent documentation
• Pre-procedure assessment including:
  • Relevant medical history and comorbidities
  • Previous anesthesia/sedation experiences and any complications 1
  • Current medications and allergies
  • Baseline vital signs (heart rate, blood pressure, respiratory rate, temperature) 1
  • Airway assessment (particularly noting any abnormalities that might increase risk) 1
  • ASA physical status classification 1

Technical Aspects of Procedure

• Type of epidural (lumbar, thoracic, cervical, caudal)
• Patient position during procedure
• Aseptic technique details
• Anatomical landmarks used
• Approach used (midline or paramedian) 2
• Level of insertion (vertebral interspace)
• Loss of resistance technique (saline or air) 2
• Depth to epidural space (in cm)
• Catheter insertion details:
  • Distance inserted beyond needle tip
  • Final catheter depth at skin
  • Catheter fixation method 2
• Test dose administration:
  • Medication used (typically bupivacaine with epinephrine)
  • Dose administered (typically 3mL containing 15mg bupivacaine and 15mcg epinephrine) 3
  • Patient response to test dose
  • Assessment for intravascular or intrathecal placement 3

Medication Administration

• Specific medications administered:
  • Local anesthetic (type, concentration, volume)
  • Opioids (if used, type and dose)
  • Any other additives
• Total dose of each medication administered 1
• Time of administration 1
• Route of administration (clearly labeled as epidural) 1
• Person who prepared and administered the medication 1

Patient Monitoring and Response

• Vital signs monitoring during procedure
• Patient response to epidural placement
• Assessment of sensory and motor block (level and degree)
• Complications or adverse events during procedure and their management
• Post-procedure vital signs and neurological assessment

Post-Procedure Orders and Instructions

• Epidural infusion details (if continuous infusion):
  • Medication composition
  • Concentration
  • Rate of infusion
  • Parameters for adjustment
• Monitoring requirements
• Breakthrough pain management plan
• Parameters for contacting anesthesia provider
• Catheter removal plan

Safety Considerations to Document

• Confirmation that resuscitation equipment was immediately available 3
• Documentation of epidural catheter labeling at injection site and insertion site 1
• Verification that epidural medication was properly labeled with:
  • Drug name and concentration
  • Patient identifier
  • Date and time of preparation
  • Route of administration clearly marked 1

Common Pitfalls to Avoid

1. Inadequate test dose documentation: Always document test dose administration and assessment for intravascular or intrathecal placement 3

2. Incomplete medication labeling: Ensure all epidural medications are clearly labeled with route, concentration, and time of preparation to prevent medication errors 1

3. Failure to document catheter depth: Always record both insertion depth and final catheter position to help identify potential catheter migration 2

4. Missing assessment of block level: Document the sensory and motor block achieved to establish baseline for future comparisons

5. Inadequate complication documentation: Any complications during placement must be thoroughly documented along with interventions performed

By including all these elements in epidural procedure notes, clinicians create a comprehensive record that enhances patient safety, facilitates appropriate monitoring, and provides essential information for managing potential complications.