Epidural Placement Note Generator

Patient / Case Information

Patient name

MRN / DOB

Age / Sex

Weight (kg)

Height (cm)

Location

Date & time of placement

Placing provider

Assisting personnel

History of Present Illness

Indication for epidural

Labor analgesia Postoperative analgesia (planned surgery) Chronic pain management Other (see narrative)

HPI narrative

Surgical Procedure

Planned / performed procedure

Surgical service

Labs & Relevant Studies

Platelet count

INR / PT

aPTT

Hgb / Hct

Creatinine

Last anticoagulant & dose

Time of last anticoagulant dose

Other pertinent labs / studies

Pre-Procedure Exam

Back exam

Landmarks palpable Midline easily identified Scoliosis / spinal deformity Previous back surgery / instrumentation Signs of infection at planned site Other abnormality noted

Baseline neurologic exam

Sensation intact bilaterally Motor strength intact bilaterally No focal neurologic deficits Abnormal finding (see narrative)

Baseline vital signs

Exam detail / narrative

Placement Details

Time out completed

Technique

Loss of resistance to saline Loss of resistance to air Midline approach Paramedian approach Ultrasound-guided Landmark-guided Sitting position Lateral decubitus position Tunneled

Level

Needle type / gauge

Number of attempts

Depth to loss of resistance (cm)

Catheter threaded beyond needle tip (cm)

Catheter depth at skin (cm)

Test dose medication

Bupivacaine Lidocaine Epinephrine 1:200,000

Test dose result

Negative for intravascular placement Negative for intrathecal placement Positive — intravascular Positive — intrathecal Not performed

Complications during placement

None Paresthesia during placement Blood noted in needle/catheter Dural puncture (wet tap) Difficult / multiple attempts Other (see narrative)

Exam after placement

Deferred Appropriate sensory deficit for incision

Placement detail / complication narrative

Anesthesia Plan

Infusion medication(s)

Starting infusion rate (mL/hr)

Rate range (mL/hr)

Other analgesic recommendations

Scheduled PCM and NSAID Gabapentin or pregabalin Morphine Additional adjuncts

Anticoagulation while epidural is in place

Prophylactic heparin or enoxaparin

May be administered May not be administered

Therapeutic heparin or enoxaparin

May be administered May not be administered

Likely duration of epidural therapy

Additional anesthesia plan notes

Precautions & Nursing Call Parameters

Aim to optimize epidural function and reduce opioid use Adjustments only to be made by anesthesia team

Call anesthesia team for

Additional precautions / special instructions