Combined Sedation Form Preview

Comprehensive Procedural Sedation Record — 5-Part Form: Pre-Assessment · Medications · Monitoring · Recovery & Discharge · Adverse Events

[HOSPITAL NAME]

Procedural Sedation Program

FORM F-13

Comprehensive Procedural
Sedation Record

Minimal Moderate Deep

Affix Patient Label Here

Name:

MRN:

DOB:

Procedure / Location

Proceduralist

Sedation Provider

Baseline Vitals (BP/HR/SpO₂)

Pre-Sedation Assessment (Form F-13 equivalent)

Sedation Consent Signed & in Chart

ASA Class

I II III IV E

Airway & Aspiration Risk

Normal Airway / Low Aspiration Risk High Risk (Document plan below)

NPO Status

Compliant Violated

Allergies & Meds

NKDA Yes:

Rescue Readiness Reversal agents & airway equip. present

Sedation Medication Record (Form F-13 equivalent)

Time	Medication	Dose / Route	Cumulative Total	Patient Response / Notes	Initials

Intra-Procedural Monitoring (Form F-13 equiv. • Chart q5 Min)

Time	BP	HR	RR	SpO₂ (Cont.)	EtCO₂ (If req)	Sedation Score*	O₂ (L/m) / Device	Interventions / Comments

*Sedation Score (Ramsay): 1=Anxious/Agitated, 2=Cooperative/Tranquil, 3=Responds to commands, 4=Brisk response to light tap, 5=Sluggish response, 6=No response.

Sedation Recovery & Discharge (Form F-13 equivalent)

Discharge Criteria Met? Airway patent & unassisted; Respirations regular Vitals stable and within 20% of baseline Returned to baseline consciousness / easily arousable Pain and Nausea (PONV) controlled Surgical/Procedure site checked (No active bleeding)

Final Aldrete/PADSS Score:

(Must be ≥ 9)

Instructions & Escort Written discharge instructions provided to patient/family and discussed. Responsible adult escort confirmed (Required for discharge home after sedation).

Escort Name:

Relation:

Time of Discharge:

Adverse Event & Escalation Record (Form F-13 equivalent)

Did any adverse event or complication occur? NO (Uneventful) YES (Check all that apply below)

Events Apnea / Hypoventilation Airway Obstruction Desaturation (SpO₂ < 90%) Aspiration (Suspected/Confirmed) Severe Hypotension / Bradycardia

Interventions & Escalation Reversal Agent Used (Naloxone) Reversal Agent Used (Flumazenil) Anesthesia Backup Called Code Blue / Rapid Response Unplanned Intubation / Airway Rescue

Combined Sedation Form Preview

[HOSPITAL NAME]

Comprehensive ProceduralSedation Record

Comprehensive Procedural
Sedation Record