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):

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:

Yes
No

If under age 9:

Protective reflexes
Easily arousable
Sit up unassisted

Discharge Vitals: (BP)

Discharge Vitals: (02Sat.)

Discharge Vitals: (HR)

Discharge Vitals: (RESP)

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**:

Comments / Complications:

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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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Clinic HOURS:
Monday 7:30-7:30pm
Tuesday 7:30-3:30pm
Wednesday 7:30-3:30pm
Thursday 7:30-7:30pm
Friday 7:30-3:00pm

Clinic Closed: Dec 26/27 & 30

Open Dec 28 & Dec 29 7:30-2:00pm

Back to regular business Jan 2 2023 7:30-7:30pm.

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Address:
102-1500 Bank street Ottawa, Ontario K1H 7Z2
613-706-4101
Info@blueherondentalgroup.ca