Nitrous Oxide Sedation Record

Patient Name: [Patient full name]   DOB: [MM/DD/YYYY]   MRN: [Medical record number]   Sex: [M / F / X]   Weight (kg): [Weight in kg]
Date of Service: [MM/DD/YYYY]   Location/Operatory: [Operatory or room]
Operating Dentist: [Name, credentials]   Sedation Provider: [Name, credentials] (If same as operating dentist, note "same.")   Monitor/Assistant: [Name(s), role]
Procedure(s) and Site: [Dental procedure(s) and specific site(s)/tooth numbers]

Sedation Plan

Modality: N₂O/O₂ inhalation
Planned Sedation Depth: [minimal / moderate]
Indication(s): [anxiety / gag reflex interference / special health care needs / lengthy procedure / other: specify] (Select all that apply.)
Planned Adjuncts: [Local anesthetic: agent and plan] [Additional sedatives: none / planned: name, dose, route] (If any sedative beyond local anesthetic is planned, note that moderate sedation documentation requirements apply.)

Pre-Sedation Assessment

• Allergies / Prior Adverse Reactions: [Drug, latex, food allergies and reactions; prior sedation/anesthesia issues] (If none, document "No known allergies.")
• Current Medications: [Name, dose, frequency, last dose timing if relevant]
• Relevant Medical History: [Respiratory disease; cardiac conditions; OSA/snoring history; recent URI; pregnancy status when applicable; prior sedation/anesthesia issues; other pertinent conditions]
• Airway Assessment:
  • Mouth opening/interincisal distance: [Assessment or unable to assess: reason]
  • Neck mobility: [Assessment or unable to assess: reason]
  • Mallampati class: [I / II / III / IV] (Include when moderate sedation is planned.)
  • Tonsillar size: [Assessment] (Include for pediatric patients.)
  • Craniofacial concerns: [None / findings: micrognathia, midface hypoplasia, nasal obstruction, other]
  (If any element cannot be assessed due to cooperation or other limitation, document the reason rather than leaving blank.)
• ASA Physical Status: [I / II / III / IV] (If ASA III or higher, include brief rationale.)
• Fasting Status: Last solids: [time/date]; Last clear liquids: [time/date] (Document when moderate sedation is planned, adjunct sedatives are used, or per policy. For minimal N₂O-only anxiolysis where fasting is not required, note dietary precautions reviewed or not indicated per policy.)
• Baseline Vitals: BP [mmHg]; HR [bpm]; RR [breaths/min]; SpO₂ [% on room air] (If unable to obtain any value, document the reason.)
• Baseline Mental Status and Cooperation: [Alertness, orientation, anxiety level, cooperation, communication ability]

Informed Consent

Sedation consent obtained from [patient / guardian (relationship: specify)] on [date] at [time]. Risks, benefits, and alternatives discussed; questions answered.
Dental procedure consent: [obtained separately / included above]
Protective stabilization consent: [obtained] (Only include if stabilization is planned or used.)

Pre-Procedure Safety Checklist

• Oxygen source adequate and available: [yes / no]
• N₂O delivery system safety features verified (scavenging, fail-safe, proportioning, alarms): [yes / no]
• Monitors functional — pulse oximeter: [yes / no]; BP cuff: [yes / no]; capnography: [yes / no / not used]
• Emergency equipment and drugs available and checked: [yes / no]
• Suction available and functional: [yes / no]

Time-Out Completed: [yes / no] at [HH:MM] — Patient identity verified; procedure and site confirmed; allergies reviewed; team ready to proceed.

Sedation Administration Record

Start Time: [HH:MM] (Beginning of O₂/N₂O administration)

N₂O Titration Log:

Time	N₂O %	O₂ %	Patient Response/Comments
[HH:MM]	[%]	[%]	[Observed effect, comfort, adverse symptoms]

(Add rows for each titration adjustment with patient response at each change.)

Maximum N₂O Percentage: [%]
Total N₂O Duration: [minutes]

Local Anesthetic: [Agent, concentration, volume (mL), total dose (mg), vasoconstrictor if applicable, time(s) administered]
Other Medications: [Name, dose, route, time, effect] (Only include if administered.)

Intra-Procedure Monitoring

(Record at 5–15 minute intervals depending on sedation depth and at key procedural events.)

Time	N₂O/O₂ (%)	SpO₂	HR	RR	BP	Sedation Level	EtCO₂	Comments
[Procedure start HH:MM]	[N₂O% / O₂%]	[%]	[bpm]	[/min]	[mmHg]	[minimal / moderate]	[mmHg / N/A]	[Start; baseline status]
[HH:MM]	[N₂O% / O₂%]	[%]	[bpm]	[/min]	[mmHg]	[minimal / moderate]	[mmHg / N/A]	[Milestones, patient responses, interventions]
[Procedure end HH:MM]	[N₂O% / O₂%]	[%]	[bpm]	[/min]	[mmHg]	[minimal / moderate]	[mmHg / N/A]	[End of procedure]

(Include EtCO₂ when capnography is used for moderate sedation; otherwise mark N/A. If any parameter cannot be obtained, document reason in Comments.)

Adverse Events

(Only include this section if an adverse event occurred.)

• Event Type: [hypoxemia / airway obstruction / emesis / oversedation / agitation / equipment malfunction / other: specify]
• Time of Onset: [HH:MM]   Resolution: [HH:MM]
• Associated Vitals: [Pertinent values and trends]
• Interventions: [repositioning / suction / increased O₂ / N₂O discontinued / positive-pressure ventilation / other: specify]
• Patient Response/Outcome: [Clinical response and status post-intervention] (Brief direct quotes acceptable for subjective symptoms.)

Recovery and Discharge

N₂O Stop Time: [HH:MM]
Post-Oxygenation: [100% O₂ for X minutes / alternative protocol: specify]

Recovery Monitoring:

Time	SpO₂ (RA)	HR	RR	BP	Mental Status	Comments
[HH:MM]	[%]	[bpm]	[/min]	[mmHg]	[At baseline / near baseline]	[Observations]

(Continue monitoring until discharge criteria are met. Document return to baseline responsiveness and stable oxygenation on room air.)

Discharge Criteria Met: Airway patent [yes / no]; Cardiovascular stable [yes / no]; Responsiveness at baseline [yes / no]; Protective reflexes intact [yes / no]
Discharge Authorized By: [Clinician name, credentials] confirms criteria met.

Discharge Vitals: HR [bpm]; RR [/min]; BP [mmHg]; SpO₂ [%] (Include when moderate sedation occurred, adjunct sedatives were used, adverse events occurred, or per policy. For uncomplicated minimal N₂O-only cases, may note return to baseline without incident per policy.)

Discharge Instructions Provided To: [Patient / Guardian (relationship: specify)] — understanding confirmed: [yes / no]
Instructions Reviewed: Sedation precautions (dizziness, nausea, activity restrictions); dental procedure care; when to seek urgent care; emergency contact; follow-up plan

Signatures

Sedation Provider: [Signature] [Printed name, credentials] [Date/Time]
Monitor: [Signature] [Printed name, credentials] [Date/Time] (Include if separate from sedation provider.)
Discharge Authorized By: [Signature] [Printed name, credentials] [Date/Time]