Moderate Sedation Note (Radiology/IR)

Date of Service: [Date]

Facility/Location: [IR suite / CT / MR / Angiography lab / Other]

Procedure(s): [Procedure name(s)]

Sedation Type: [minimal / moderate] — Intended level: [minimal / moderate]; Achieved level: [minimal / moderate] (If achieved level exceeded intended, document rationale and management.)

Personnel and Roles

Sedation Supervisor: [Name, credential] (If unavailable, document "Unable to obtain—[reason]".)

Procedure Operator: [Name, credential]

Monitoring Professional: [Name, credential] (Individual whose primary role is patient monitoring during sedation.)

Medication Administrator: [Name, credential]

Resuscitation Capability: [ACLS-trained personnel immediately available / Other]

Indication and Sedation Plan

• [Indication for sedation: anxiety / anticipated pain / need for immobility / prior intolerance / other]
• [Target sedation level and any constraints on depth]
• [Contingency criteria for escalation to anesthesia or procedure pause/abort]

Pre-Sedation Assessment

Focused History: [Prior sedation/anesthesia adverse events or difficult airway; relevant comorbidities (cardiac, pulmonary, OSA, hepatic/renal impairment, severe GERD); current medications/substances affecting sedation; allergies and reactions; NPO status with time of last solids and liquids; baseline pain and anxiety levels; pregnancy status if applicable] (If any item cannot be obtained, document "Unable to obtain—[reason]".)

Focused Exam: [Baseline vitals (BP, HR, RR, SpO₂); brief cardiopulmonary assessment; airway assessment per protocol (e.g., Mallampati, mouth opening, neck mobility, dentition); baseline mental status and responsiveness]

Risk Stratification: [ASA Physical Status class if used locally; high-risk flags (difficult airway concern, high aspiration risk, OSA)] (Omit if ASA class not standard at facility.)

Consent: [Sedation risks, benefits, and alternatives discussed; consent obtained; specify if separate or combined with procedure consent; if waived or obtained from surrogate, document basis]

Pre-Procedure Safety Checks

• [IV access established and patent]
• [Oxygen delivery plan and baseline O₂ requirement]
• [Monitoring initiated with alarms set]
• [Reversal agents and airway equipment available]
• [Timeout/verification completed] (Note if combined with procedural timeout.)

Intra-Procedure Sedation Record

Time Documentation

Sedation Start Time: [HH:MM] (First sedative/analgesic dose administered.)

Sedation End Time: [HH:MM] (Continuous face-to-face attendance ends and patient stable for recovery.)

Total Sedation Time: [Minutes] (If times are estimated, note as approximate with reason.)

Medications Administered

Time	Medication	Dose/Route	Administered By	Response/Notes
[HH:MM]	[Medication name]	[Dose / Route]	[Name, credential]	[Patient response]

Cumulative Totals: [List cumulative doses for key agents, e.g., total midazolam, fentanyl]

Monitoring Summary

Continuous monitoring performed throughout the procedure. See nursing sedation record for interval vital signs and alarm parameters.

• Monitoring modalities: [Continuous SpO₂, capnography if used, ECG if indicated, noninvasive BP]
• Supplemental oxygen: [Device and flow rate]
• Patient status: [Overall responsiveness and clinically significant changes or trends]
• Positioning/environment: [Considerations if relevant, e.g., prone, MR] (Omit if not applicable.)

Interventions and Complications

(Document adverse events using problem–action–response format. If none, state "No sedation-related adverse events or complications.")

• [Event/problem]: [Action taken] — [Patient response/outcome] [Time]
• [Reversal agent if given: name, dose, route, time, response]
• [Escalation to anesthesia or procedure pause/abort if occurred]

Complications Summary: [No sedation-related adverse events or complications / Complications as documented above]

Recovery

Recovery location: [Location]

[Patient status: return toward baseline mental status and airway patency; pain and nausea assessment and treatment] (If reversal agents administered, document extended observation and reassessment for re-sedation.)

See nursing recovery record for detailed vital sign documentation.

Discharge Readiness Score: [Modified Aldrete or local score and value] (Include if used at facility.)

Discharge Readiness and Disposition

Disposition: [Home with escort / Inpatient unit / ICU / Observation]

Discharge Criteria Met:

• [Vitals stable]
• [Mental status returned to baseline]
• [Motor function returned to baseline]
• [Pain and nausea controlled]
• [No ongoing airway/ventilatory/hemodynamic support required beyond destination capability]

Instructions: Written post-sedation safety instructions provided (impaired judgment precautions, no driving, return precautions, contact information). [Reference procedure-specific discharge packet if applicable]

Attestation

[Sedation supervising clinician name, credential]: I was [present / immediately available] per policy during the sedation period. The patient [tolerated sedation without complications / experienced complications as documented above with resolution]. Continuous monitoring documentation is recorded in the designated sedation flowsheet.