ESP Block Checklist + Clinical Note Generator

Procedure Date: Time: Operator: Assistant: Supervisor:

BEFORE THE PROCEDURE

Team members introduce themselves and allocate roles Yes

Patient identity checked? Yes

Appropriate consent completed? Yes

Procedure + site confirmed by patient/consent? Yes

Site marked & checked against imaging/consent? Yes

Operator discussed plan (sedation/analgesia/FiO₂)? Yes

Known drug allergies?

Yes No

Coagulopathy? (drugs/labs)

Yes No

Any contraindications?

Yes No

PROCEDURE DETAILS

Indication for the procedure:

Aseptic technique used:

Sterile gloves Hat & mask Sterile drape 0.5% chlorhexidine

Procedure performed under:

GA Sedation Awake

Position:

Lateral Sitting

Prep/stop/block

Yes No

USS

Yes No

Local anaesthetic to skin:

None Lidocaine 1% Lidocaine 2%

Volume:

Needle used for the block: Local anaesthetic:

Catheter inserted:

Yes No

Length secured at the skin: Is the patient being transferred to an appropriate ward to manage the catheter?

Difficult procedure?

Yes No

Any other comments:

Generated clinical note

Paste this note into the patient PPM record and set the title as “ESP block”.