Created Dec 2019
If a patient is given a nerve block documented only on the operation record by a surgeon at the beginning of the procedure, are we able to code the block as anaesthesia?
Firstly, check the anaesthetic form for documentation of the block. If there is no documentation about the block on the anaesthetic form consult with clinician.
In cases where no further information is available and the documentation within the operation note indicates the block was administered at the beginning of the procedure and/or there is no documentation indicating the block was administered at the end of the procedure, the nerve block can be coded as a form of anaesthesia.