Pre- Procedural Sedation Documentation

It is critical that an assessment is performed and note signed prior to starting sedation. To be clear, we are not compliant if you perform an exam, perform the sedation, and then write your note later. It is attending responsibility to ensure the note is signed prior to sedating the patient. We have asked nursing leadership to instruct nurses involved in sedation to ask and check for completion of physician pre-sedation assessment prior to starting a PRS, however you are still ultimately responsible for the note's completion. This note is separate from your regular ED encounter provider note.

Step-by-step

1. Click on "my note" tab

2. Click "Create note" (blank note)

3. On the top bar under the note tab click on the box titled "Insert SmartText"

4. Type "PRS"

5. Select "LL PRS PRE-SEDATION ASSESSMENT"

6. Complete assessment and sign

After PRS, if the patient is deemed stable for discharge, please ensure that the patient receives instructions/return precautions related to their sedation. A great clinical reference to attach under the dispo tab is titled "Sedation, Procedural Adult".

It is generally good practice to document on the patient's mental status and recovery from PRS in your MDM in your normal provider note.