Patient Label

Sedation/Analgesia Document

City and Sandwell Hospitals Unit:

Date Team:

Name of the Procedure: Routine/Urgent IP/OP

Procedure Location: Likely Discharge to:

Check: Consent Allergy Nil by Mouth Equipment Airway

Presedation Assessment

Temp HR Cardiac Rhythm Resp

BP O2 Sats (Room Air/ O2 Supple)

Pain Scale Sedation Scale

Any current medications :

Drugs Used:

Post Sedation Assessment

Yes	No	Post Sedation Assessment
2	0	Vital Signs Unchanged
2	0	Oxygen Sats Unchanged
1	0	Swallow, Cough, Gag Reflexes Present
2	0	Alert or Unchanged
2	0	Walk/Sit or Unchanged
1	0	Minimal Nausea or Dizziness
		Total > 8 – Discharge or Transfer < 8 – Should be Assessed prior to Discharge or Transfer

Discharged : Transferred To:

Filled in by: