Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location
  • MRN

  • Name of Procedure


  • Vital Sign ( BP, Heart Rate, SPO2, Temperature)

  • Glascow Coma Scale

  • Allergy acknowledgement

Consent Completion

  • Informed consent - Complete the procedure name, benefit and risk with all signatures

  • Procedural Sedation - Complete with the procedure name, benefit, risk and all signatures.

  • Fall Risk Completion

  • Pain Assessment and Reassessment Completion

  • Pre-procedural Checklist completion

  • Starting Sedation Narrator


  • Time-Out Completion

  • Vital Sign every 5 minutes

  • Any Anticipation is documented in NOTES


  • Sign out Completion

  • Vital Sign and GCS Monitoring

  • Fall Risk Updated

  • Pain Assessment and re-assessment

  • Nursing Care Plan

  • Transfer/ Discharge Assessment

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.