Office-Based Sedation/Anesthesia Record

Patient name: [Patient name]    DOB: [DOB]    MRN: [MRN]    Date of service: [Date]    Facility/location: [Facility/location]    Procedure room: [Procedure room]

Procedure (planned and actual if different): [Planned procedure; actual procedure if different]    Laterality/site: [Laterality/site]

Anesthesia/sedation type and intended depth: [minimal sedation / moderate sedation / deep sedation / MAC / general anesthesia] (If plan changed, indicate both intended and achieved depth.)

Anesthesia clinician: [Name, credentials]    Proceduralist: [Name, credentials]    Dedicated monitor (if different): [Name, role]

Allergies (with reaction type): [Allergies or "No known allergies"]    ASA status: [ASA I / II / III / IV / V / VI]    Key risk factors: [OSA, difficult airway history, cardiopulmonary disease, or other major risk factors]

Pre-anesthesia evaluation: [See location/date] (Reference existing evaluation rather than duplicating content.)

Time Record

(Use 24-hour format. Record actual timestamps; do not infer from medication or monitor trends.)

• Anesthesia start: [HH:MM]
• Anesthesia end: [HH:MM]
• Total anesthesia minutes: [Total minutes]
• Procedure start: [HH:MM]
• Procedure end: [HH:MM]
• Arrival to recovery: [HH:MM]
• Discharge time: [HH:MM]

Interruptions (if any): [Interruption start HH:MM–stop HH:MM; rationale]

Handoff (if any): [HH:MM; receiving clinician name/role]

Timing limitations (if any): [Reason time could not be recorded; basis for estimate]

Monitoring Setup

• Monitoring modalities: [Pulse oximetry / ECG / NIBP / Capnography-EtCO₂ / Temperature / Other]
• Oxygen delivery: [Method] at [Flow rate L/min or FiO₂ %]
• Equipment check: [Attestation of equipment checks completed per protocol]
• Exceptions/limitations (if any): [Standard monitor omitted or unreliable; reason]

Pre-Sedation Baseline and Time-Out

• Baseline vitals (pre-medication): [HH:MM] — HR [value], BP [value], RR [value], SpO₂ [value] on [room air / supplemental O₂]
• Baseline mental status: [Alertness/orientation/behavioral status]
• Weight: [kg] (Include when weight-based dosing applies.)
• IV access: [Site, gauge, patency confirmed]
• Time-out performed: [HH:MM] — Confirmed patient identity, procedure, site/laterality, allergies, critical concerns.

Intra-Procedure Physiologic Flowsheet

(Document at minimum every 5 minutes during sedation/anesthesia. Document immediately after each medication administration. Increase frequency during instability or interventions.)

Time	HR	BP	RR	SpO₂	EtCO₂	EtCO₂ waveform	Level of consciousness	O₂ delivery/flow	Ventilation (if mechanical)	Comments/events
[HH:MM]	[value]	[value]	[value]	[value]	[value]	[present / intermittent / absent]	[responsiveness description]	[method, flow]	[mode; rate; Vt; PEEP; FiO₂]	[notes]
[HH:MM]	[value]	[value]	[value]	[value]	[value]	[present / intermittent / absent]	[responsiveness description]	[method, flow]	[mode; rate; Vt; PEEP; FiO₂]	[notes]

(Add rows as needed to meet documentation frequency.)

Medication Administration Log

(Chronologic log of sedatives, analgesics, anesthetics, adjuncts, reversal agents, local anesthetics, oxygen/inhaled agents.)

Time	Medication	Dose (concentration if relevant)	Route	Site	Administered by	Effect/Response
[HH:MM]	[Medication]	[Dose]	[IV / IM / PO / IN / Inhaled / Other]	[Site]	[Name/role]	[Effect] (Required for first doses, escalations, rescues, adverse reactions.)
[HH:MM]	[Medication]	[Dose]	[Route]	[Site]	[Name/role]	[Effect]

Infusions (if any): [Start HH:MM; rate; changes with times; stop time; total volume]

Local anesthetic details: [Agent; total mg; mg/kg; site; administered by]

Oxygen/inhaled agent adjustments: [Times, flows/concentrations, durations]

Airway Management

• Ventilation approach: [spontaneous / assisted / controlled]
• Airway interventions: [No airway interventions required; oxygen via (method)] (If no interventions beyond routine oxygen.)
• Basic maneuvers/adjuncts (if used): [HH:MM] — [jaw thrust / chin lift / oral airway / nasal airway / suctioning / repositioning]
• Advanced airway (if placed): Device [type/size]; attempts [number]; placement [HH:MM]; confirmation [methods]; complications [details]; removal [HH:MM]
• Capnography waveform: [present throughout / intermittent (reason) / unavailable (reason)]

Events, Complications, and Interventions

(Time-stamped narrative. Categories: hemodynamic, respiratory, neurologic/behavioral, medication-related, operational.)

• [HH:MM] — [Event observed]. Intervention: [action with time]. Response: [outcome].

[No adverse events or complications.] (State explicitly if none occurred.)

Transfer of Care

• Anesthesia end time: [HH:MM]
• Condition at transfer: Airway [status]; Breathing [adequacy]; Hemodynamics [stable / unstable]; Consciousness [description]; Pain [score/status]; Nausea [status]
• Ongoing concerns (if any): [e.g., risk of re-sedation after reversal]
• Handoff: [HH:MM] to [Name, role, location]

Recovery Monitoring

(Include for moderate or deeper sedation, MAC, general anesthesia, or cases with airway events, reversal agents, or instability. Omit for uncomplicated minimal sedation.)

Time	HR	BP	RR	SpO₂	Consciousness	Pain	Nausea	Airway/Respiratory	O₂ delivery	Interventions/Comments
[HH:MM]	[value]	[value]	[value]	[value]	[description]	[score]	[score]	[description]	[method, flow]	[notes]
[HH:MM]	[value]	[value]	[value]	[value]	[description]	[score]	[score]	[description]	[method, flow]	[notes]

• Symptoms and treatments: [Pain, nausea, dizziness; treatments with times and responses]
• Milestones (if applicable): [Tolerated oral intake / ambulated / voided] with times

Discharge Assessment

• Discharge criteria met: [Yes / No (reason)]
• Final assessment: Mental status [returned to baseline / acceptable]; Vital signs [stable]; Airway/respiratory [adequate]; Oxygenation [adequate on room air / on supplemental O₂]; Pain [controlled]; Nausea [controlled]; Bleeding [controlled] (if applicable); Ambulation [at baseline] (if applicable)
• Criteria/scoring system: [Aldrete / PADSS / Other] Score: [value]
• Discharging clinician: [Name, credentials]
• Disposition: [Discharged home with responsible escort / Transferred to ED/hospital / Admitted]
• Discharge instructions provided: [Yes / No (reason)]    Escort present: [Yes / No (reason)]

Authentication

Signature: [Anesthesia clinician name, credentials]    Date/Time signed: [Date HH:MM]

Late entry/amendment (if any): [Current timestamp; reason; preserve original documentation]