This customizable document, Sedation Monitoring Form, is taken from MCN Healthcare’s Leadership Manual. For more than 20 years, MCN has been the health care industry’s leading provider of policy and procedure templates, forms, competencies and other compliance tools.

Health care organizations around the world utilize MCN’s compliant ready templates and workflow process tools to help them meet the latest changes in regulations and standards.

Here is some sample content from Sedation Monitoring Form:

	SEDATION MONITORING Patient Name: PREPROCEDURE ASSESSMENTArrival Date: Time: Time MD Notified: ? Patient ID Explanation of procedure/sedation given: ? Yes Patient accepts plan for sedation: ? Yes Patient to be discharged to care of: Possibility of pregnancy? Preg. test results: Diagnosis: Chief Complaint: Continuous IV inf. Solution Rate Cath Site Time: Signature: T P R B/P O2 Sat LOC Height Weight Allergies: Current Meds/Supplements: Type sedation planned: ASA Class by MD: RespiratoryCardiovascularNeurologicalPsychological? Regular? ...
Second excerpt:
	...Boney Prominence Gonadal ShieldBody Wt: Bolus: Cont. Infusion: Procedure Performed: Procedure Started: Procedure Ended: Monitored By: Assisted By: MD: Sent to Lab - Pathology: PAIN MANAGEMENT:Epidural Test Dose at TimeTrigger Points:FACET BLOCK: Cervical Thoracic LumbarXylocaine 1.5% MPF Epinephrine 1:200,000 1.5 mL ? Negative ? Positive Left POST PROCEDURE MONITORINGTo PACU at timeTimeBPPRO2 SatPatient Response/LOCInterventionPatient Transferred to: Discharge Criteria Met: ...