Emergency Department Procedural Sedation Note

Date/Time of sedation: [Date and time]
Location: [ED / trauma bay / procedure room / other]
Patient weight: [Weight] kg ([measured / stated / estimated])
Sedation status: [performed / planned but not performed]
Sedation classification (intended): [minimal / moderate / deep / dissociative]
Sedation classification (achieved): [minimal / moderate / deep / dissociative / N/A if not performed]
Procedure: [Procedure name], [Site/laterality: left / right / bilateral / midline / N/A]
Proceduralist: [Name and role]
Sedation provider: [Name and role]
Independent monitor: [Name and role]
Interpreter: [Not used / Language, modality: in-person / video / phone]
Special circumstances: [Trauma activation / critical airway risk / pregnancy / none]

Indication

[Indication narrative: why sedation is needed, urgency, painful vs anxiety-provoking nature, alternatives considered, non-pharmacologic adjuncts used] (2–4 sentences)

Pre-Sedation Evaluation

[Focused history] (Address relevant cardiopulmonary/neurologic disease, OSA, hepatic/renal impairment, prior sedation complications, current sedating medications/substances, allergies to planned agents, last oral intake with time and type, baseline mental status, pregnancy status if applicable. Document that urgency and risk/benefit were weighed rather than treating NPO status as automatic contraindication. If history unobtainable, state which elements, why, and surrogate sources reviewed.)

• Baseline vital signs: HR [value], BP [value], RR [value], SpO2 [value]% [on room air / on supplemental O2 at L/min]
• Airway assessment: Mallampati [I / II / III / IV / unable to assess: reason]; mouth opening [adequate / limited]; neck mobility [full / limited]; relevant anatomy [beard / obesity / facial trauma / loose teeth / dentures / none] (Do not infer from prior notes; if not assessed, state why.)
• ASA Physical Status: [I / II / III / IV / V / VI] [E if emergent] (Do not infer from prior documentation.)
• Risk stratification: [Risk/benefit statement and whether anesthesia consultation was considered or obtained]

Consent

[Consent documentation] (Include: who consented [patient / surrogate], format [written / verbal], sedation-specific risks discussed [respiratory depression, aspiration, hypotension, allergic reaction, emergence phenomena, potential intubation], alternatives discussed. For emergency exception: document why delay would jeopardize outcome, attempts to reach surrogate, and that care proceeded under implied/emergency consent per institutional policy.)

Pre-Procedure Verification

• Time-out performed: [Time], verified: correct patient, procedure, site/laterality, allergies, team roles confirmed
• Equipment readiness: Suction [ready]; oxygen [ready]; BVM [ready]; airway adjuncts [accessible]; monitoring [applied and functional]; IV access [confirmed / not obtained: reason and backup plan]; reversal agents [available / N/A]

Sedation Plan

• Target sedation depth: [minimal / moderate / deep / dissociative]
• Primary agent: [Agent name], [initial dose and titration plan] (For pediatrics: [dose] mg/kg based on [weight] kg)
• Adjunct analgesia: [none / agent and dosing]
• Oxygen delivery: [room air / nasal cannula at L/min / facemask / NRB]
• Monitoring: Continuous pulse oximetry; ECG [yes / no]; NIBP q[interval] min; capnography [yes / no: reason and mitigation if no]
• Backup airway equipment: [Equipment and plan]

Medications Administered

(If sedation not performed: "No sedatives or analgesics administered." and omit medication list.)

• [Time] — [Medication], [Dose] [units], [route], [sedative / analgesic / adjunct] (Pediatrics: [mg/kg] based on [weight] kg)
• (Repeat for each medication chronologically.)

Total doses: [Agent: total dose; repeat for each agent]

Reversal agents: [None / Agent, dose, time, response] (If given, note extended observation required.)

Airway and Respiratory Interventions

• [Time] — [Intervention: repositioning / jaw thrust / chin lift / suctioning / OPA / NPA / BVM / supraglottic airway / intubation], [indication], [response]
• (Add entries as needed.)

(If none required: "No airway interventions required beyond supplemental oxygen.")

Procedure Course

• Sedation start: [Time]
• Procedure start: [Time]
• Procedure end: [Time]
• Sedation end: [Time]

[Procedure course narrative: sedation depth achieved, patient tolerance, redosing. Document complications (desaturation/apnea, hypotension/bradycardia, vomiting, laryngospasm, emergence reaction, agitation) with interventions and response. If no complications, explicitly state: "No hypotension, bradycardia, or hemodynamic instability. No desaturation, apnea, or airway compromise. No vomiting or aspiration events."]

(If aborted: document reason, medications given, and patient status afterward.)

Recovery

• Recovery start: [Time]
• Monitoring: Vitals q[interval] min, continuous SpO2 [yes / no]
• Mental status: [Returned to baseline / baseline abnormal: description]
• Airway/respiratory: [Patent, tolerating room air / requires support: description]
• Hemodynamics: [Stable / intervention required: description]
• Pain: [Assessment and treatment if needed]
• Nausea/vomiting: [Absent / present: treatment and response]
• Recovery score: [Aldrete or institutional: score] [Threshold met: yes / no / not used]
• Disposition-ready: [Time]
• Extended observation triggers: [Reversal agent / long-acting sedative / repeated dosing / persistent hypoxia / ongoing emesis / abnormal neuro status / none]

Disposition

[Disposition: discharge home / admission / OR / transfer / observation unit]. [For discharge: responsible adult escort confirmed, activity restrictions communicated, return precautions given, follow-up plan. For admission/handoff: receiving service, location, ongoing monitoring needs, status at handoff.] (Document that instructions were provided; omit instruction content.)