See below for an example of a drop-down template for ultrasound-guided emergency nerve block.  This is what we now use at Highland.  Further down there is a generic checklist; it basically covers the basics of a safe ED block.  The documentation sheet relates more toward the technical details of a safe block.

Regional Block Procedural Checklist

1) Patient is identified, 2 criteria.  Appropriate identifying data entered in ultrasound machine.

2) Allergies and anticoagulation status are reviewed.

3) Consent for block and any associated procedure is confirmed.

4) Appropriate neurologic and vascular exam completed and documented.

5) Block plan is confirmed*, site is marked.

6) Necessary equipment is present, drugs are labeled. 

7) Resuscitation equipment is immediately available: airway devices, suction, vasoactive drugs, lipid emulsion.**

8) Appropriate monitors are applied; intravenous access, sedation, and supplemental oxygen are provided, if indicated.

9) Aseptic technique is used: hand cleansing is performed, and sterile gloves are used.

10) “Time out” is performed before needle insertion.

*Block plan should include complementary balanced analgesia and anxiolysis, appropriate matching of block to procedure/injury, appropriate timing of the block placement for optimal benefit, acquisition of block ultrasound image, post-block monitoring and care, and consultation with collaborating services involved with patient care.

Peripheral Nerve Block Procedure Template

Procedure

A right [left][superficial cervical plexus, brachial plexus-interscalene, brachial plexus-supraclavicular, brachial plexus-axillary, radial, median, ulnar, femoral, saphenous, popliteal sciatic, posterior tibial, intercostal, greater auricular, [free text]] nerve block was performed. 

Patient was [was not] identified, using 2 criteria

After explanation of the risks benefits and alternatives verbal [written] consent was obtained. 

Pre-procedure neurological exam findings: 

A neurologic exam was conducted including motor and sensory testing of the [free text] nerve.  There were no deficits. [The following deficits were found: [free text]]. Extremity compartments were [soft, tense, not assessed]. 

Procedural details: 

The patient was [was not] maintained on continuous cardiac and pulmonary monitoring throughout the procedure.

“Time out” was[was not] performed before needle insertion.

The area of injection was prepped with chlorhexidine [betadine]. Sterile technique was observed using: [+] sterile gloves, [+] sterile ultrasound probe cover, [+] sterile drape, [+] cap, [+] face mask. 

A [25, 22, 20, 18 [free text]] gauge [hypodermic, quincke tip, blunt tipped block, Touhy [free text]] needle, [free text] mm in length, was used.

Ultrasound guidance with real-time visualization of the needle tip was [was not] utilized throughout the procedure using an in-plane [out-of-plane] approach.  Images were [were not] saved.

Approximately 5 [1, 2, 3, 4, 6, 7, 8, 9, 10, 15, 20, 25, 30] mL of 1 [0.25,0.5, 2, 3] % lidocaine without epinephrine [lidocaine with epi, bupivacaine, ropivicaine, chloroprocaine] was injected near the nerve structure.  Local anesthetic was [was not] gradually injected in small aliquots of 3-5 mL following negative aspiration.  Low-pressure injection was confirmed using [manometer, compressed air technique]. A peripheral nerve catheter was [was not] left in place and dressed.

There was no [was] significant pain or paresthesias during the procedure. There were no [were] signs of local anesthetic toxicity. There were no [were] other complications. [free text]

Following the procedure, the blocked extremity was [was not] protected [positioned] to prevent injury and was marked with provider initials and time of the block.