PROCEDURAL SEDATION RECORD SEDATION FORM

PROCEDURAL SEDATION
RECORD
Ka‘u
Hale Ho‘ola Hamakua
Date ______ /______ /______ Arrival Time: _________ Procedure Start: __________ Consent: YES
Procedure: ________________________________________________________________________
Diagnosis: ________________________________________________________________________
Procedure M.D. ___________________________ Referring M.D. ____________________________
NPO since: ____________ Latex Allergy No Yes Ht: ________ inches Wt: ________ kg lbs
Allergies (food & drugs):______________________________________________________________
Med/Surg History: __________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
______________________________________________ Reviewed H&P Yes LMP:____________
Medications: ______________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
ASA Class (circle) 1 2 3 4 5 Score = __________
I have assessed the patient and have determined that they
are a candidate for sedation.
Sedation Plan: moderate deep
MD Initials: __________ Date _____________ Time __________
CLASS I CLASS II CLASS III CLASS IV
LAB VALUES REVIEWED Yes No NOTE CRITICAL VALUES
DATE TEST VALUE DATE TEST VALUE
For procedures requiring IV contrast: Contrast History Yes
Total contrast administered: _______ ml
Contast Type:________________________________________________
Total Fluoro Time: ________ minutes
IV THERAPY / IV ACCESS / ANTIBIOTIC ADMINISTRATION
Type of Access: Peripheral Right Left Central Other:
Size / Gauge:
Start Time:
SOLUTION RATE SITE VOLUME INFUSED
Activity
Resp
Circulation
Right
Left
ALDRETE SCORE PRE/POST
PRE POST
PRE POST
Consciousness
O2 Sat
Total Score
PULSES: LIST AS DOPPLER OR 1+ TO 4+
RADIAL DP PT AVG OTHER
MEDICATION DOCUMENTATION - OBTAIN VS & PRE-INDUCTION ASA JUST PRIOR TO INJECTING MEDICATION
Time: PRE-INDUCTION VS OCCURS BEFORE FIRST MED
Time
Versed
Fentanyl
MEDICATIONS
Note IV or IG = Intragraft
IA = Intra-arterial
Totals
NURSING PRE-ASSESSMENT: LUNG SOUNDS: ______________________________________________ EKG: ______________________ PAIN: ____________________
Syringes/bowls labeled on and off sterile field Site verified Pt/MD/RN POSITION: __________________
TIME OUT BEFORE INCISION/PROCEDURE START: @ __________ SEE UNIVERSAL PROTOCOL FORM
TIME B/P HR RESP SpO2 O2
Sedation
PAIN Temp optional ________
CARDIOVASCULAR WNL
RHYTHM
Scale
SCALE COMMENTS COLUMN
CONTINUOUS EKG MONITOR
PRE-INDUCTION VS & AIRWAY REASSESSMENT(*)
Time: PRE-INDUCTION VS OCCURS BEFORE FIRST MED
RN/CRNA SIGNATURE: ___________________________________ DISCHARGE TIME: _______________ INSTRUCTIONS DISPOSITION: ___________ ACC. BY______________
I attest to the above documentation: MD Sig: ___________________________________________ Initials: _____________ Date: ____________________ Time: ______________
FORM 322-0379 Rev. 4/10
WHITE: MEDICAL RECORD YELLOW: QM DEPT.
SEDATION FORM

PROCEDURAL SEDATION
RECORD
PAIN
TIME B/P HR RESP SpO2 O2 LOS RHYTHM SCALE
COMMENTS
SCORE
2
1
0
ACTIVITY
Moves all 4 extremities
Moves 2 extremities
Moves 0 extremities
ASA Physical Status
I. Healthy patient
II. Mild systemic disease -
no functional limitations
III. Severe systemic disease -
with functional limitations
IV. Severe systemic disease that is a
constant threat to life
V. Moribund patient not expected to
survive 24 hours
Modified Aldrete Post Anesthesia Recovery Score
RESPIRATIONS
CIRCULATION CONSCIOUS O2 SATURATION
Able to cough & deep breath BP+/- 20% of pre-procedure level Fully awake
Dyspnea limited breathing or BP+/- 20 to 49% of preprocedure
Arousable on calling
tachypnea
level
Apneic or on mechanical vent BP+/- 50% of pre-procedure level Not responding
LEMON
Airway Assessment tool
• Look Externally
• Evaluate the 3-3-2 rule
• Mallampati Score
• Obstruction
• Neck Mobility
Sedation Scale
1. None - Wide awake
2. Mild - Drowsy
3. Moderate - Dozing
intermittently
4. Sleep - Normal sleep
5. Severe - Difficult or unable
to arouse
SpO2 > 92% on room air
Requires supplemental O2 to keep SpO2 >
92%
SpO2 < 92% with supplemental O2
Time Out definition: Just prior to incision/procedure, the following items are checked:
• Correct patient identity
• Confirmation that the correct side and site are marked
• An accurate procedure consent form
• Agreement on the procedure to be done
• Correct patient position
• Relevant images and results are properly labeled and appropriately displayed
• The need to administer antibiotics or fluids for irrigation purposes
• Safety precautions based on patient history or medication use

PROCEDURAL SEDATION
RECORD
Ka‘u
Hale Ho‘ola Hamakua
Date ______ /______ /______ Arrival Time: _________ Procedure Start: __________ Consent: YES
Procedure: ________________________________________________________________________
Diagnosis: ________________________________________________________________________
Procedure M.D. ___________________________ Referring M.D. ____________________________
NPO since: ____________ Latex Allergy No Yes Ht: ________ inches Wt: ________ kg lbs
Allergies (food & drugs):______________________________________________________________
Med/Surg History: __________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
______________________________________________ Reviewed H&P Yes LMP:____________
Medications: ______________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
ASA Class (circle) 1 2 3 4 5 Score = __________
I have assessed the patient and have determined that they
are a candidate for sedation.
Sedation Plan: moderate deep
MD Initials: __________ Date _____________ Time __________
CLASS I CLASS II CLASS III CLASS IV
LAB VALUES REVIEWED Yes No NOTE CRITICAL VALUES
DATE TEST VALUE DATE TEST VALUE
For procedures requiring IV contrast: Contrast History Yes
Total contrast administered: _______ ml
Contast Type:________________________________________________
Total Fluoro Time: ________ minutes
IV THERAPY / IV ACCESS / ANTIBIOTIC ADMINISTRATION
Type of Access: Peripheral Right Left Central Other:
Size / Gauge:
Start Time:
SOLUTION RATE SITE VOLUME INFUSED
Activity
Resp
Circulation
Right
Left
ALDRETE SCORE PRE/POST
PRE POST
PRE POST
Consciousness
O2 Sat
Total Score
PULSES: LIST AS DOPPLER OR 1+ TO 4+
RADIAL DP PT AVG OTHER
MEDICATION DOCUMENTATION - OBTAIN VS & PRE-INDUCTION ASA JUST PRIOR TO INJECTING MEDICATION
Time: PRE-INDUCTION VS OCCURS BEFORE FIRST MED
Time
Versed
Fentanyl
MEDICATIONS
Note IV or IG = Intragraft
IA = Intra-arterial
Totals
NURSING PRE-ASSESSMENT: LUNG SOUNDS: ______________________________________________ EKG: ______________________ PAIN: ____________________
Syringes/bowls labeled on and off sterile field Site verified Pt/MD/RN POSITION: __________________
TIME OUT BEFORE INCISION/PROCEDURE START: @ __________ SEE UNIVERSAL PROTOCOL FORM
TIME B/P HR RESP SpO2 O2
Sedation
PAIN Temp optional ________
CARDIOVASCULAR WNL
RHYTHM
Scale
SCALE COMMENTS COLUMN
CONTINUOUS EKG MONITOR
PRE-INDUCTION VS & AIRWAY REASSESSMENT(*)
Time: PRE-INDUCTION VS OCCURS BEFORE FIRST MED
RN/CRNA SIGNATURE: ___________________________________ DISCHARGE TIME: _______________ INSTRUCTIONS DISPOSITION: ___________ ACC. BY______________
I attest to the above documentation: MD Sig: ___________________________________________ Initials: _____________ Date: ____________________ Time: ______________
FORM 322-0379 Rev. 4/10
WHITE: MEDICAL RECORD YELLOW: QM DEPT.
SEDATION FORM