Moderate Sedation Presentation - Mayo Clinic Health System

Physician/Provider Pre-Procedure Responsibilities
(To be completed and signed by the provider performing the procedure and/or the provider administering the sedation)
Complete the
H&P – Pre
Procedure
Assessment
form
CC
HPI
Past Medical
History
Physical Exam/Review of
Systems
ASA Classification
( one)
Chief Complaint:__________________________________________________________________
HPI:____________________________________________________________________________________
Medications reviewed Allergies reviewed Record reviewed
No change from H & P of___________ (date) (must be within 30 days)
Illnesses:________________________________________________________________________________
Previous Surgeries:________________________________________________________________________
Family History/Social History:________________________________________________________________
NOTE: If H & P is less than 30 days, only heart Pre-Procedure Airway Assessment
and lung assessment/examination is required.
Yes No
□ Vital Signs Reviewed
History of difficult intubation or surgical
airway (i.e trach):
Normal Abnormal
Inability to extend neck:
Heart _______________________
Lungs _______________________ Mouth opening less than two finger
breadth:
Neuro _______________________
Diagnosis of sleep apnea:
Abdomen _______________________
Mental Status _______________________ Less than three finger breadth to hyoid
bone:
Other pertinent to exam:_________________________
_____________________________________________
1 Healthy, normal
2 Mild systemic
disease
3 Severe systemic
disease
4 Severe systemic
disease constant
threat to life
5 Moribund
No functional limitations, midl
obesity, DM w/o complications, HTN
some functional limitation, stable
angina, morbid obesity, controlled
COPD/Asthma/CHF
Unstable angina, active symptoms of
COPD/Asthma, CHF/HTN
Circle appropriate
class.
Informed consent obtained after discussion of risks, benefits, alternatives and potential
complications. Patient/guardian understands and desires to proceed.
Plan for Sedation
Plan
Patient re-evaluated immediately prior to moderate sedation
Medication: Versed Fentanyl Demerol Morphine Ketamine * Etomidate *
Other:_____________________________________________________
* = Requires provider with advanced intubation skills present during sedation.
Plan: Moderate Sedation MAC
Post Sedation Plan of Care: Departmental Post Procedure Area Inpatient Room PACU
Other:________________________________________________________________________________
Impression: _________________________________________________________________
Treatment Plan:______________________________________________________________
Provider Signature:____________________Pager:______Date:___________ Time:________
TRIAL NS-1003 we/forms/H P sedation 6/30/10
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