Monitored Anesthesia Care (MAC) Sedation Note

Date/Time: [Note creation date and time]

Location: [endoscopy / cath lab / interventional radiology / imaging / other non-OR site]

Procedure: [Procedure name and laterality if applicable]

Proceduralist(s): [Name(s)]

Anesthesia Provider(s): [Name(s) and role(s)]

Preanesthesia Evaluation

(Use concise, high-signal bullet points. Omit bullets that are not applicable. If critical history is unobtainable, document the reason and note that available records were reviewed.)

• Indication for MAC: [Patient and/or procedure factors requiring MAC rather than proceduralist-directed moderate sedation] (Reference increased risk, need for deeper sedation, or readiness to convert to general anesthesia. If not explicitly documented, use: "MAC service provided per procedural request and patient risk profile as assessed below.")
• Focused History:
  • Sedation/airway/hemodynamic conditions: [OSA / COPD / cardiac disease / GERD or aspiration risk / hepatic impairment / renal impairment / other relevant conditions]
  • Prior anesthesia/sedation issues: [none reported / PONV / difficult airway / emergence agitation / awareness / other]
  • Medications of anesthetic relevance: [anticoagulants / antiplatelets / chronic opioids / benzodiazepines / GLP-1 agonists / other] (List only those relevant to anesthetic risk or management.)
  • Allergies: [Agent(s) and reaction type(s)]
  • NPO status: [Last solids / last clear liquids]; aspiration risk modifiers: [GERD / gastroparesis / obesity / pregnancy / other]
  • Baseline functional status: [Estimated METs or brief descriptor] (Include if relevant to risk assessment.)
• Focused Physical Exam:
  • Vitals: [Current vitals or "refer to most recent documented vitals"]
  • Airway: Mallampati [I / II / III / IV]; mouth opening [adequate / limited]; thyromental distance [adequate / reduced]; neck mobility [full / limited]; dentition [intact / dentures / loose teeth / missing teeth / poor dentition]; [obesity / beard if applicable]
  • Cardiopulmonary: [Heart sounds, rhythm, murmurs if present]; [breath sounds, work of breathing]
  • IV access: [Site, gauge, patency]
  • Exam limitations: [Components limited and reason] (Include only if exam was limited.)
• Pertinent Data Reviewed: [Key labs, ECG, imaging, or other diagnostics affecting anesthetic risk] (If none reviewed or indicated, state "none indicated.")
• ASA Physical Status & Risk Flags:
  • ASA status: [I / II / III / IV / V] [E if emergent]
  • Risk flags: [aspiration risk / anticipated difficult airway / hemodynamic fragility / limited physiologic reserve / other] (Omit if none.)
• Anesthetic Plan:
  • Sedation depth: [minimal / moderate / deep]
  • Airway strategy: Baseline [natural airway with supplemental O2 via nasal cannula / simple face mask / HFNC]; Rescue [oral airway / nasal airway / BVM / SGA / ETT / conversion to GA]
  • Monitoring: [ECG / NIBP / SpO2 / capnography / temperature]
  • Medications approach: [Primary sedatives and analgesics with general dosing strategy]
  • PONV prophylaxis: [not indicated / indicated: planned agent(s)]
  • Positioning/access considerations: [Positioning, procedural constraints, radiation considerations] (Include if relevant.)
• Informed Consent: [Obtained from patient / obtained from legally authorized representative / not obtained due to emergent circumstances per policy]; risks, benefits, and alternatives discussed.

Intraoperative MAC Summary

[1–2 sentence overview of MAC technique: airway management approach, oxygen delivery method, patient positioning.] (Reference the anesthesia record/flowsheet for time-based vitals and detailed medication administration.)

• Monitoring: [ECG / NIBP / SpO2 / capnography / temperature] (If capnography was not used when sedation depth would typically warrant it, document the reason and mitigation.)
• Medications & Fluids: Sedatives/analgesics: [agents with total doses]; IV fluids: [type and volume]; Reversal agents: [agent, dose, and indication] (Include reversal agents only if given.)
• Airway & Respiratory Events: [Event, intervention, and response] (Include only if airway interventions or respiratory events occurred.)
• Hemodynamic Events & Complications: [Event, treatment, and response] (Include only if significant events occurred.)
• Disposition: Destination: [PACU / phase II recovery / ICU / discharge area]; Status at transfer: [level of consciousness, airway patency, hemodynamic stability]; Handoff: [key information communicated to receiving staff]

Postanesthesia Evaluation

Evaluation Time: [Timestamp] Location: [Recovery location]

(The following domains are required. If a domain cannot be assessed, state "unable to assess" with the reason. Do not leave blank.)

• Respiratory: RR [value]; airway [patent / supported]; SpO2 [value] on [room air / supplemental O2 with delivery method and flow]
• Cardiovascular: HR [value]; BP [value]; [stable / changed from baseline]
• Mental Status: [alert and oriented / drowsy but arousable / sedated]; [at baseline / returning to baseline / not at baseline]
• Temperature: [Measured value or clinical assessment per policy]
• Pain: [Severity score]; [adequately controlled / requires intervention]
• Nausea/Vomiting: [absent / present]; [treatment if applicable]
• Hydration: [Status]; oral intake: [tolerating / not yet attempted / not tolerating]

Complications in Recovery: [Complication, treatment, and outcome] (Include only if complications occurred.)

Discharge/Transfer Readiness:

• Status: [meets discharge criteria / does not meet criteria]
• Discharge score: [Scoring system used] — [score] (Include if institutional policy requires.)
• For ambulatory discharge: [Responsible adult escort confirmed; written instructions provided per policy] (Include for ambulatory patients only.)
• If not ready for discharge: [Reason and plan]