Abstract:
Documentation after regional nerve block is an essential component of patient pain
management. It will safeguard against medico legal issues, it will increase the successful
performance of regional anesthesia, to safely follow patients having nerve block, to
improve patient’s recall of risks and benefits, to get briefed information during hand over
of pain management and to request written rather than verbal communication during hand
over of pain management. However, there are no specified protocols which should be
recorded for each individual nerve block, less adequate documentation form and there is
interpersonal variation during documentation here in this setup. So, we aimed to determine
whether regional nerve block documentation trends in University of Gondar referral
hospital meet the standards or not.
Methods: A cross sectional study is conducted from February 1-May 30, 2018.All patients
who were given regional nerve block for postoperative pain management in the study
period were included. A checklist used for data collection is prepared based on NYSORA
Guideline recommendations.
Results: Forty-four record sheets were audited after patient’s exposure of regional nerve
block. The aseptic technique was documented for all patients. The level of documentation
was >85% for name of the nerve block and the availability of standard monitoring.
However, the level of completeness of documentation was done below 50% for signature
of service provider, consent, attempts of the technique, length of the procedure, approach
of the nerve block, size of the needle, site of the block, time out period and level of
sedation and indication of the nerve block. Conclusion and recommendation: The level
of documentation after regional nerve block was unsatisfactory in our hospital compared
with the recommendations of NYSORA guideline. So training should be given for all
anesthetists who will be involved in regional nerve block and regular re auditing should be done to attain the given standards.
