Improving Documentation:
RAAPM Forms

Although the creation of a paper form is a simple endeavor, the processes of creating the forms on this page were controversial for several reasons. First, in creating the content of any form thoughtfully, it is important to appreciate that the practice of medicine can be guided or even changed. This is a good thing. For example, if you do not want practitioners to give more than four grams of acetaminophen to adult patients per day, you can specify the dosing parameters on the form. Second, most of these forms were created for use at a single institution, while a few were created by a group from several institutions. We have learned that even practitioners who practice very similarly may have very different ideas about the content of such forms. For example, our own institution’s “Anesthesia Risk Disclosure” form underwent seventeen revisions and still not all users like the form. Third, anesthesia practitioners are sometimes polarized as to whether having any type of form in the first place is even a good idea. (This is especially true in regard to written anesthesia consent forms. We believe our form helps to document the process of consent as well as to function as a patient educational tool.) Other practitioners feel that even order entry forms stifle autonomy. Lastly, while most of these forms are created with the idea of a paper page in mind, most are now used in electronic format which greatly changes the format and utility of each form.

1. Peripheral Nerve Block Procedure Note
   (authors: Gerancher JC, Viscusi ER, Liguori GA, McCartney CJ, Williams BA, Ilfeld BM, Grant SA, Hebl JR, Hadzic A. Development of a standardized peripheral nerve block procedure note form. Reg Anesth Pain Med. 2005;30:67-71.)
2. Neuraxial Block Procedure Note
   (authors: Viscusi ER, Gerancher JC, Copeland S, Weller RS. American Society of Regional Anesthesia 30th Annual Spring Meeting Toronto April 21-24 th 2005. abstract)
3. Regional Anesthesia Procedure Note
4. Information for Outpatient Continuous Peripheral Nerve Block Infusions
5. Extended Release Epidural Morphine (Depodur) Administration Orders
6. RAAPM Initial Consultation or Evaluation and Management Note
7. Standard IV PCA Order Form
8. Non-Standard IV PCA Order Form
9. Continuous and Patient Controlled Epidural Infusion Orders
10. Continuous and Patient Controlled Neural Blockade Infusion Orders
11. Anesthesia Risk Disclosure Form
12. Anesthesia Risk Disclosure Form in Spanish
13. Wound Infusion Orders

Pain Management Policies and Procedure Forms

1. Pain Management
2. IV PCA
3. Intraspinal Opioid (including EREM)
4. Continuous PNB
5. Wound Infusion

(authors for form numbers 3-13: Regional Anesthesia and Acute Pain Management Section at WFU)

 

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DISCLAIMER: The forms found on this page used at the author's institution, are being updated frequently. They are provided as illustrations to guide the development of forms at the reader's own institution. Although some of these forms have been previously published, their content should not be considered to be peer reviewed. The author and his institution do not endorse use of these forms at outside institutions without careful, appropriate review and modification by the user.

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