Conscious Sedation



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.