Procedural Sedation Record

Procedural Sedation Record Patient Identification: [Record patient’s full name, hospital folder number or RSA ID (if available), date of birth, and gender] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Procedure Details: [Describe the procedure performed, including type (e.g. fracture reduction, abscess drainage, gastroscopy), location (e.g. ED, procedure room, clinic), estimated duration, and responsible proceduralist or team] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Sedation Indication: [State the clinical reason for sedation, including urgency, pain/anxiety relief, or need for procedural cooperation; note any contraindications considered] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Pre-Sedation Assessment: [Document fasting status if applicable, baseline vital signs, airway risk assessment (e.g. Mallampati, loose teeth, obesity), known comorbidities (e.g. HIV, TB, epilepsy, asthma), and relevant examination findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Sedation Plan: [Specify the sedation strategy planned, including selected agents (e.g. ketamine, midazolam, propofol), analgesics (e.g. morphine, fentanyl), dosage ranges, administration routes (IV, IM), and titration method] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Monitoring: [Describe parameters monitored (e.g. HR, BP, SpO₂, RR, level of consciousness), equipment used (manual vs electronic), and frequency of observations] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Administration Log: [Time-stamped record of all sedative, analgesic, and adjunct medications administered, including dose, route, and administering clinician or nurse] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Sedation Depth and Responsiveness: [Record depth of sedation using a standardised scale (e.g. AVPU, Ramsay Sedation Score) and note patient’s level of responsiveness throughout] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Intra-Procedure Course: [Summarise procedure duration, patient response, haemodynamic or respiratory changes, airway support required (if any), and any sedation-related or procedural complications] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Fluids and Adjuncts: [Record IV fluid volumes administered, use of local anaesthetics, antiemetics, or other supportive medications] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Complications and Adverse Events: [Document any sedation-related adverse events (e.g. desaturation, hypotension, agitation, vomiting, laryngospasm), and any interventions undertaken] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Recovery Assessment: [Note recovery vital signs, level of consciousness, ability to maintain airway, orientation status, and readiness for discharge or transfer from recovery area] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Post-Sedation Instructions: [Document discharge instructions including need for escort, activity restrictions, dietary advice, medication guidance, red flags to watch for, and follow-up arrangements] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Clinician Signature: [Name and designation of the clinician responsible for sedation documentation (e.g. medical officer, EM registrar, anaesthetist), and time/date of completion] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care. Use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that the information has not been explicitly mentioned in your output. Leave the relevant placeholder or section blank if it is not explicitly mentioned. Use as many full sentences as needed to capture all the relevant information from the transcript.)