Procedural Sedation

Chief Complaint

Procedural Sedation

Template

Procedural Sedation PMHx and Anethesia History: Reviewed. Pertinent history includes: [pertinent history] Medications: Reviewed. Pertinent meds include: [pertinent medications] Allergies: Patient has [allergy status]. Physical Exam: BP [blood pressure] (BP Location: [BP location], Patient Position: [patient position]) | Pulse [pulse rate] | Temp [temperature] °C ([temperature method]) | Resp [respiratory rate] | SpO2 [oxygen saturation] There is [neck ROM]. Mouth opening is [mouth opening]. Mallampati: [ ] I [ ] II [ ] III [ ] IV Dentition: [dentition status] CVS: [CVS findings] Resp: [respiratory findings] Weight: [weight] kg ASA: [ ] 1 Healthy, non-smoker [ ] 2 Mild systemic disease (smoker, well-controlled systemic dx) [ ] 3 Severe systemic disease (poorly controlled systemic dx) [ ] 4 Severe systemic disease with constant threat to life [ ] 5 Moribound/immediate threat to life Procedural Sedation & Analgesia Log Informed verbal consent for procedural sedation obtained after discussion of risks, benefits and alternatives. Patient on cardiopulmonary monitoring with supplemental O2 via [oxygen delivery method] + ETCO2 monitoring. Suction and airway equipment at the bedside. IV established and fluids running. Position: [patient position during procedure] Medications Used: [medications used] Anesthesia start time: [anesthesia start time] Anesthesia end time: [anesthesia end time] The patient tolerated the procedure well. No peri-procedural hypotension or hypoxia. Post procedure condition: [ ] Stable Condition [ ] Unstable Condition [ ] Awake [ ] Rousable [ ] Somnolent The patient was monitored by nursing staff and can be discharged home when alert, awake and ambulatory. Discharge instructions were provided to the patient/family. The patient was advised not to drive or operate any heavy equipment for the next 24 hours. The patient will be taken home by a [transportation arrangement]. [Optional:] The patient was advised to return to the ED if there is any rash, tongue/lip/mouth swelling, shortness of breath, chest pain, wheezing, dizziness or any other concerns.