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Sample Parenteral Conscious Sedation Record

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Sample Parenteral Conscious Sedation Record

Patient Information

Patient (Full Name):

Gender (M/F):

Dental Procedure(s):

ALLERGIES (Agent, Reaction):

Relationship:

Birthdate – M/D/Y:

Date – M/D/Y:

MEDICATIONS (Name, Dose, Frequency):

ESCORT (Verified Pre-Sedation) Name:

Phone #:

Any other sedatives taken?(eg:Lorazepam, marijuana, alcohol):

ASA:

BMI:

Physical Exam:

Pre-Sedation Vitals: (Blood Pressure)

Pre-Sedation Vitals: (Heart Rate)

Age:

NPO:

Assessment:

Pre-Sedation Vitals: (O2 Sat.)

Pre-Sedation Vitals: (RESP.)

WT (kg):

Last Solids:

Review of Systems:

WNL*
Teeth
Airway
C.V.S
Resp
Neuro
GI
GU
Prev. Anesth. Prob.

HT:

Last Fluids:

Monitors:

NIBP
SpO2
ECG
ETCO2

Other:

Intended Level of Sedation:

Minimal
Moderate

Deepest Level of Sedation Obtained:

Minimal
Moderate
Deep
General

Indication(s) for Sedation:

Anxiolytics/Sedatives Taken Night Before Dental Appointment: (Name):

Anxiolytics/Sedatives Taken Night Before Dental Appointment (Dose):

Anxiolytics/Sedatives Taken Night Before Dental Appointment (Time):

Anxiolytics/Sedatives Taken Prior to Arrival to Dental Facility: (Name)

Anxiolytics/Sedatives Taken Prior to Arrival to Dental Facility: (Dose):

Anxiolytics/Sedatives Taken Prior to Arrival to Dental Facility: (Time):

Non-Sedative/Sedative Premedication: (Name)

Non-Sedative/Sedative Premedication: (Dose):

Non-Sedative/Sedative Premedication: (Time):

Post Sedation Recovery

Time:

BP:

Pulse:

RESP:

SpO2

Time:

BP:

Pulse:

RESP:

SpO2

Time:

BP:

Pulse:

RESP:

SpO2

Time:

BP:

Pulse:

RESP:

SpO2

Oriented to person / place / time:

If under age 9:

Protective reflexes
Easily arousable
Sit up unassisted

Discharge Vitals: (BP)

Discharge Vitals: (02Sat.)

Discharge Vitals: (HR)

Discharge Vitals: (RESP)

Vital Signs Stable:

Pre-Sedation Level Of Ambulation:

Written Post Sedation Instruction Given:

Verbal Post-Sedation Instruction Given:

Recovery Notes:

Fit Time For Discharge Time:

Recovery Supervisor:

In The Company Of: (Name)

In The Company Of: (Relationship)

In The Company Of: (Phone)

In The Company Of: (Patient Left The Facility Ad)

Signatures:

DDS:

RN / RT:

Sedation Provider:

DA:

Signature:

Sedation

Drug Name:

Local Anesthetic Name:

IV Fluids Name:

Dose:

Total:

Wasted:

O2 L/min:

N2 O L/min:

SpO2 %:

RESP /min:

ECG (if applicable):

LOS**:

Drug Name:

Local Anesthetic Name:

IV Fluids Name:

Dose:

Total:

Wasted:

RESP /min:

ECG (if applicable):

LOS**:

O2 L/min:

N2 O L/min:

SpO2 %:

Drug Name:

Local Anesthetic Name:

IV Fluids Name:

Dose:

Total:

Wasted:

O2 L/min:

N2 O L/min:

SpO2 %:

RESP /min:

ECG (if applicable):

LOS**:

Time: (Start Sedation)

Time: (Start Procedure)

Time: (End Procedure)

Time: (End Sedation)

To Recovery Room:

IV I Size:

IV I Type:

DOH
ACF
FA
Wrist
Arm
Foot

Difficult:

IV II Size:

IV II Type:

DOH
ACF
FA
Wrist
Arm
Foot

Difficult:

BP:

HR:

Comments / Complications:

Phone

New To The Clinic ?

Blue Heron Dental Group is built on a strong reputation of over 30 years of service to the Ottawa community and the families who live here. Other dentists in the community refer pediatric patients to our clinic due to our experience and reputation when treating children.

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