PERIPHERAL NERVE BLOCK RECORD (Single-Shot)
Hospital: ________________________ | Dept of Anesthesia	Form Code: F-17 | Version: ___ | Effective: ___ | PAGE 1 of 1

PATIENT DETAILS
Name: _______________________________	MRN: _______________	DOB/Age: _________	Wt (kg): _____
Allergies: ☐ Drug: __________________________________     ☐ Latex     ☐ CHG

BLOCK DETAILS	PRE-BLOCK SAFETY
Block name: ________________________________ Laterality: ☐ R    ☐ L    ☐ Bilateral Indication: ☐ Surgical anesthesia ☐ Postop analgesia ☐ Other: ___________________________	☐ Consent confirmed ☐ Stop-Before-You-Block completed (F-17) ☐ Baseline neurovascular exam documented:   ☐ Yes   ☐ No   ☐ N/A ☐ Anticoag reviewed & acceptable:   ☐ Yes   ☐ No   ☐ N/A      Last dose/time: ________________________ ☐ LAST kit + lipid available & in date:   ☐ Yes   ☐ No

TECHNIQUE	MONITORING & SEDATION
Guidance: ☐ Ultrasound    ☐ Nerve stimulator    ☐ Landmark Needle (type/gauge/length): ________________________________________________ Approach/notes: ________________________________________________	Monitoring applied: ☐ NIBP    ☐ SpO₂    ☐ ECG Sedation used: ☐ None ☐ Yes (drug/dose): ________________________________ ________________________________________________

LOCAL ANESTHETIC DOSE & ADJUVANTS					DOSE CHECK
Drug	Conc (%)	Total Volume (mL)	Total mg	Adjuvant	☐ Within limit (Calculated Max Dose verified safe)

INJECTION SAFETY
Incremental injection used:    ☐ Yes   ☐ No Frequent aspiration performed:    ☐ Yes   ☐ No US spread observed (if US):    ☐ Yes   ☐ No   ☐ N/A	Pain/paresthesia during injection: ☐ No    ☐ Yes (action): _________________________ High resistance/pressure: ☐ No    ☐ Yes (action): _________________________

OUTCOME & COMPLICATIONS
Sensory block: ☐ Adequate    ☐ Partial    ☐ Failed Motor effect: ☐ None    ☐ Expected    ☐ Excessive	Complications: ☐ Vascular puncture    ☐ Hematoma    ☐ Pneumothorax ☐ LAST symptoms    ☐ Persistent neuro deficit concern ☐ Other: __________________________________________ Post-block instructions issued: ☐ Limb protection    ☐ Sling    ☐ Fall risk precautions    ☐ Discharge advice

SIGNATURES
Operator: Name: ___________________________________________ Sign: __________________________ Time: ____________	Assistant/Witness: Name: ___________________________________________ Sign: __________________________ Time: ____________