Procedural Sedation Documentation Audit

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• MRN

• Name of Procedure

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

  Met

  Not Met

  Not Applicable

• Glascow Coma Scale

  Met

  Not Met

  Not Applicable

• Allergy acknowledgement

  Met

  Not Met

  Not Applicable

Consent Completion

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

  Met

  Not Met

  Not Applicable

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

  Met

  Not Met

  Not Applicable

• Fall Risk Completion

  Met

  Not Met

  Not Applicable

• Pain Assessment and Reassessment Completion

  Met

  Not Met

  Not Applicable

• Pre-procedural Checklist completion

  Met

  Not Met

  Not Applicable

• Starting Sedation Narrator

  Met

  Not Met

  Not Applicable

• Time-Out Completion

  Met

  Not Met

  Not Applicable

• Vital Sign every 5 minutes

  Met

  Not Met

  Not Applicable

• Any Anticipation is documented in NOTES

  Met

  Not Met

  Not Applicable

• Sign out Completion

  Met

  Not Met

  Not Applicable

• Vital Sign and GCS Monitoring

  Met

  Not Met

  Not Applicable

• Fall Risk Updated

  Met

  Not Met

  Not Applicable

• Pain Assessment and re-assessment

  Met

  Not Met

  Not Applicable

• Nursing Care Plan

  Met

  Not Met

  Not Applicable

• Transfer/ Discharge Assessment

  Met

  Not Met

  Not Applicable