DOCUMENTATION
- Invasive Procedure Consent Form
- Time Out Form
PROCEDURE NOTE
Performed by: [Provider Name]
Indications: [ ]
Universal Protocol: a time out was performed and the correct patient and site were verified
Consent: The risks and benefits of monitored anesthesia care, including the risk of aspiration, deep sedation requiring airway management including possible intubation, nausea/vomiting and the risks of not performing the procedure, including severe pain and inability to complete the procedure, were all discussed with the [patient]. The alternatives of performing the procedure, including local anesthesia and IV analgesia, also discussed. The patient has a ride home available.
ASA Class: [I-healthy / II-mild systemic disease / III-severe systemic disease / IV-incapacitating systemic disease]
Pre-anesthesia evaluation, including history, exam, and informed consent is documented in the ED note above.
Monitoring: Continuous monitoring of heart rate, respiratory rate, pulse oximetry and ETCO2. Supplemental oxygen prior to and during procedure via nasal cannula. Resuscitation equipment available at the bedside during sedation.
Intra-service start time: [00:00]
Intra-service stop time: [00:00]
The patient received [ ] and dosages were recorded on the sedation form. The patient was recovered from the sedation without complication or incident. Patient returned to pre-sedation level of awareness. The monitoring was discontinued at this time.
Post-anesthesia evaluation:
Respiratory function, cardiovascular function, temperature, and mental status [did/did not] return to pre-anesthetic state.
Pain [was/was not] controlled.
The patient [did/did not] tolerate p.o.