Moderate Sedation Record (GI Endoscopy)

Patient: [Full name], [DOB], [MRN], [sex], [weight in kg]

Date of Service: [Date]

Facility/Location: [Facility name / location]

Procedure(s): [GI endoscopy procedure(s)] (May reference separate procedure report for full details.)

Sedation Type: Moderate sedation

Indication: [Brief indication for endoscopy and sedation]

Allergies: [Allergy list with reactions, especially opioids and benzodiazepines]

Relevant Alerts: [OSA, difficult airway history, other clinically significant risk factors]

Team and Roles

Sedation Provider: [Name], [Credentials]

Proceduralist: [Name], [Credentials] (Include if different from sedation provider.)

Medication Administrator: [Name], [Credentials]

Continuous Monitor/Observer: [Name], [Credentials]

(When sedation provider is also the proceduralist, include the following attestation. If observer identity is not documented, insert "INCOMPLETE: Independent trained observer not documented.")

"An independent trained observer, [Name/Credentials], was present for continuous physiologic monitoring during the moderate sedation service and had no other concurrent duties."

Pre-Sedation Assessment

ASA Physical Status: [I / II / III / IV] [modifiers if applicable]

Airway Assessment: Mallampati [I / II / III / IV], neck mobility [normal / limited], dentition [intact / dentures / loose teeth / other], prior difficult airway [Yes / No] [details if yes]

Relevant Comorbidities: [Cardiopulmonary disease, hepatic/renal dysfunction, neurologic disease, obesity/OSA, substance use affecting sedation, pregnancy status as applicable]

Prior Sedation/Anesthesia Reactions: [None reported / details]

NPO Status: Last liquids [time], last solids [time]

Baseline Mental Status: [Alertness and ability to follow commands]

Baseline Vitals: BP [value] mmHg, HR [value] bpm, RR [value] /min, SpO₂ [value]% on [room air / supplemental O₂], Temp [value]

Equipment/Readiness Check: Oxygen source [confirmed], suction [confirmed], bag-mask device [confirmed], reversal agents (naloxone, flumazenil) [confirmed], IV access [site], [gauge], patent [Yes / No]

Time-Out Completed: [Yes / No] at [time] (Patient identity, procedure, allergies, sedation plan, and monitoring plan confirmed.)

Sedation and Monitoring Plan

Intended Sedation Depth: Moderate sedation (target: comfort with preserved purposeful response)

Sedation Scale: [MOAA/S / Ramsay / other] (Use consistently throughout documentation.)

Monitoring Modalities:

• Pulse oximetry: [Yes / No]
• NIBP interval: [every 3 min / every 5 min / other]
• ECG: [Yes / No] (If yes, indication: [reason])
• Capnography/EtCO₂: [Yes / No] (If no, reason: [reason])
• Oxygen delivery: [room air / nasal cannula / simple mask / other] at [flow rate] L/min

Sedation Intraservice Time

Sedation Start Time: [HH:MM] (Time of first sedating/analgesic dose.)

Sedation Stop Time: [HH:MM] (Patient stable for recovery transfer; sedation provider's continuous face-to-face time ends.)

Total Intraservice Time: [minutes] minutes

(Do not infer sedation times from procedure times or medication timestamps. If start, stop, or total minutes cannot be determined, insert "INCOMPLETE: Sedation intraservice time not fully documented.")

Scope times (optional, distinct from sedation time): Scope in [HH:MM], Scope out [HH:MM]

Provider Attestation: "I provided/supervised moderate sedation for [total minutes] minutes (start: [HH:MM], stop: [HH:MM])."

Medication Administration

Time	Medication (generic)	Dose + Units	Route	Administered By	Patient Response
[HH:MM]	[Medication name]	[Dose + units]	[IV / IM / other]	[Name / role]	[improved comfort / no change / excess sedation / respiratory depression / hypotension / agitation]

Cumulative Totals:

Agent	Total Dose
[Agent name]	[Total dose + units]

(If reversal agents were administered, include the following. Otherwise omit.)

Reversal Agent Details: [Agent], [dose], [time]. Response: [clinical response]. Extended monitoring plan: [duration and parameters]. Re-sedation risk counseling provided: [Yes / No].

Intra-Procedure Monitoring

(Document at regular intervals, typically every 5 minutes. For upper endoscopy where verbal response is impractical, document nonverbal responsiveness per facility protocol.)

Time	BP	HR	RR	SpO₂	O₂ Delivery	Sedation Score	Airway/Ventilation	ECG Rhythm	Comments
[HH:MM]	[value]	[value]	[value]	[value]%	[device/flow]	[score]	[unlabored / snoring / apnea / assisted]	[rhythm / N/A]	[interventions or notes]

(If any monitoring parameter cannot be obtained, document which parameter, reason, alternative assessment used, and when normal monitoring resumed.)

Adverse Events and Interventions

(Document each event separately. If no complications occurred, include only: "No sedation-related complications.")

• Time of recognition: [HH:MM]

  Event type: [hypoxemia / apnea / airway obstruction / hypotension / bradycardia / aspiration / agitation / other]

  Interventions: [Airway repositioning, jaw thrust, increased O₂, BVM ventilation, fluid bolus, medication adjustment, reversal agent, escalation]

  Response/outcome: [Patient response and stabilization]

  Escalation: [None / details including additional personnel or level of care change]

Recovery Handoff

Transfer Time: [HH:MM]

Receiving Nurse/Area: [Name / unit]

Patient Status at Transfer: [Vitals, mental status, O₂ requirement]

(If recovery monitoring and discharge scoring are documented in separate nursing documentation, reference that note here. If captured in this record, include the following.)

Recovery Vitals:

Time	BP	HR	RR	SpO₂	O₂ Delivery	Mental Status	Pain/Comfort
[HH:MM]	[value]	[value]	[value]	[value]%	[device/flow]	[description]	[score/description]

Discharge Readiness Score: [Modified Aldrete / other] = [score], criteria met: [list]

Responsible adult/escort confirmed: [Yes / No]

Post-sedation instructions provided (written and verbal): [Yes / No]

Signatures

Sedation Provider Signature: [Name, credentials, signature], [date/time]

Monitor/Observer Signature: [Name, credentials, signature], [date/time] (Include if required by facility policy.)