Date:
Patient:
Procedure:
Sedating Physician:
Pre-Procedural
History:
Past medical history (PMH) – relevant medical conditions and medications
Allergies (medications, anesthesia)
NPO status (nothing by mouth) and fasting duration
Airway assessment (potential for difficulty)
Informed consent obtained for procedure and sedation
Physical Exam:
Vital signs (blood pressure, heart rate, oxygen saturation)
Baseline mental status
Monitoring Equipment:
Pulse oximetry
ECG (electrocardiogram)
Non-invasive blood pressure monitoring
Procedural
Medication:
Name, dose, route of administration (e.g., IV) of sedating medication(s)
Time of administration
Level of Sedation:
Describe the level of sedation achieved using a standardized scale (e.g., Modified Ramsay Sedation Scale)
Procedure Details:
Brief description of the procedure performed
Any complications encountered during the procedure
Vital Signs:
Document vital signs throughout the procedure at specified intervals
Post-Procedural
Recovery:
Time to discharge from recovery area
Discharge criteria met (stable vital signs, adequate pain control, alert and oriented)
Pain Management:
Medications used for pain control
Effectiveness of pain management
Disposition:
Discharged home with instructions
Admitted for further monitoring
Complications:
Document any complications encountered during sedation or recovery (e.g., airway obstruction, hypoxia, hypotension)
Assessment:
Overall success of the sedation and procedure
Patient tolerance of the procedure
Plan:
Follow-up instructions (pain management, wound care)
Need for further evaluation or monitoring
Notes:
Include any additional relevant details not captured in other sections
Disclaimer: This template is for informational purposes only and should not be used as a substitute for clinical judgment. The specific content of a progress note will vary depending on the individual patient and procedure.