NEURAXIAL BLOCK RECORD (Spinal / Epidural / CSE)
Hospital: ________________________ | Dept of Anesthesia	Form Code: F-16 | Version: ___ | Effective: ___ | PAGE 1 of 2

B) PATIENT IDENTIFIERS
Name: _______________________________	MRN: _______________	DOB/Age: _________	Wt (kg): _____
Allergies: _______________________________________ (Latex: ☐ Yes ☐ No | Chlorhexidine: ☐ Yes ☐ No)		Location: ☐ OR  ☐ L&D  ☐ NORA  ☐ Block Area Date/Time: _______________________

C) INDICATION

☐ Surgical anesthesia    ☐ Labor analgesia    ☐ Postop analgesia    ☐ Other: ______________

D) PRE-BLOCK SAFETY
☐ Consent obtained ASA Class: ___ Baseline vitals: BP _______ / HR _______ / SpO₂ _______	Anticoag/antiplatelet reviewed & acceptable: ☐ Yes ☐ No ☐ N/A    Last dose/time: ________________________ Labs if indicated: Platelets _______ INR _______ Other: _______
Infection at insertion site: ☐ No    ☐ Yes (explain): _________________________________ Stop/concerns communicated: ☐ Yes ☐ No

E) TECHNIQUE SELECTION	F) ASEPSIS
☐ Spinal    ☐ Epidural    ☐ CSE Position: ☐ Sitting    ☐ Lateral Approach: ☐ Midline    ☐ Paramedian Level(s) attempted: _______________    # Attempts: ___	Skin prep: ☐ CHG/Alcohol    ☐ Povidone-Iodine    ☐ Other: _______ Precautions: ☐ Sterile gloves    ☐ Mask    ☐ Sterile drape ☐ Sterile gown (if required by policy)

G) PROCEDURE DETAILS
Needle type/gauge: ___________________________________
For SPINAL CSF obtained: ☐ Yes    ☐ No Drug Conc Dose Adjuvant	For EPIDURAL / CSE LOR medium: ☐ Saline    ☐ Air   |   Catheter depth at skin: _____ cm Aspiration: ☐ Negative    ☐ Positive (action): _________________ Test dose used: ☐ Yes    ☐ No   |   Details: ________________ Initial Bolus Drug Conc Vol Time

H) MONITORING & SEDATION DURING PLACEMENT

Monitoring: ☐ NIBP   ☐ SpO₂   ☐ ECG Sedation: ☐ None   ☐ Yes (drug/dose): ________________________________

I) BLOCK ASSESSMENT & EVENTS
Sensory level: ____________________ Motor block: ______________________	Complications: ☐ Hypotension    ☐ Bradycardia    ☐ High block    ☐ PDPH/dural puncture ☐ Paresthesia    ☐ Vascular puncture    ☐ N/V    ☐ Other: ___________ Actions taken + response: _____________________________________________

J) IMMEDIATE POST-BLOCK PLAN	K) SIGNATURES
Fall precautions: ☐ Yes    ☐ No Monitoring frequency: ____________________________ Postop analgesia plan: ____________________________ Handover notes to PACU/ward: __________________________________________________	Performed by: Name: ___________________________________________ Sign: __________________________ Time: ____________ Supervisor (if required): Name: ___________________________________________ Sign: __________________________ Time: ____________

NEURAXIAL BLOCK RECORD (Spinal / Epidural / CSE)
Patient Name: _________________________ | MRN: _______________	Form Code: F-16 | PAGE 2 of 2

L) CATHETER / INFUSION ORDER (if applicable)
Solution (drug + conc): ____________________________________________________________________________
Basal rate: _______ mL/hr      Bolus: _______ mL Lockout: _______ min          Max/hr: _______ mL	Start date/time: ________________________ Line labeling confirmed: ☐ Yes    ☐ No Pump settings verified (double-check if policy): ☐ Yes    ☐ No

M) NEUROLOGIC SAFETY & ESCALATION	N) ANTICOAG PLAN / RESTART
Nursing neuro checks frequency: __________________ RED FLAGS—Escalate immediately if: ☐ New/worsening motor weakness ☐ Severe back pain ☐ Bowel/bladder dysfunction ☐ Progressive numbness beyond expected distribution ☐ Fever or catheter site discharge	Restart plan (per local protocol): ________________________________________________ ________________________________________________ ________________________________________________ Removal plan reference: “Use F-16 Catheter Removal Checklist”    ☐ Noted

O) NOTES / COMMENTS

P) PAGE 2 SIGNATURES

APS / Regional Reviewer: Name: _________________________________      Signature: ___________________________      Date/Time: ________________