Moderate Sedation Audit Tool

Date of Procedure

Date

Patient Initials

MRN

Hospital

Location of procedure:

Room #:

Procedure

Proceduralist

If "Other", please list:

The privileged proceduralist documented the following:

Pre-sedation assessment (prior to the first dose of sedation)
ASA & Mallampati score (prior to start of procedure)
Ordered sedation med(s) (includes authentication of order)?

YesNo

If No, select all missing/incomplete documentation:(SELECT ALL THAT APPLY)

Documented immediately prior to first dose of sedation: Vital signs (HR, RR, BP), RASS score, SpO2, EtCO2 ?*

YesNo

If No, select all missing/incomplete documentation:(SELECT ALL THAT APPLY)

Documented intra-procedure (every five minutes,after med and until end of procedure): Vital signs (HR, RR, BP), RASS score, SpO2, EtCO2 and Immediate post procedure Modified Aldrete Score*

YesNo

If No, select all missing/incomplete documentation:(SELECT ALL THAT APPLY)

Documented every five minutes until RASS score greater than -2 or higher for two consecutive intervals, then every 15 minutes until meets sedation completion criteria: Vital signs (HR, RR, BP), RASS score, SpO2, EtCO2*

YesNo

If No, select all missing/incomplete documentation:(SELECT ALL THAT APPLY)

Documented met sedation criteria, post procedure Modified Aldrete Score and sedation discharge instructions provided to patient/pt. rep*

YesNo

If No, select all missing/incomplete documentation:(SELECT ALL THAT APPLY)

Sedation administered with no evidence of adverse event(s)?*

YesNo

If No, select all missing/incomplete documentation:(SELECT ALL THAT APPLY)

Other:

Continue for Universal Protocol Audit?

YesNo

Documented prior to the start of the Time Out the following:

Patient Identification verified? (pre-procedure & procedure room if differs)
Procedure including site / side? (pre-procedure & procedure room if differs)
Informed consent completed (within 180 days) and matches the procedure verified in above question?
H&P documented prior to procedure with sedation/anesthesia and updated if performed prior to admission?
(If outpatient, H&P performed within 30 days of procedure) – if applicable
Safety precautions reviewed based on patient history, allergies, or medication used?
Site marked by proceduralist? – if applicable
Labeled images and/or test results verified available – if applicable
Presence of equipment, devices or implants for procedure confirmed available?
Sterilization of instruments / supplies verified? – if applicable
Pre-sedation / anesthesia assessments documented? (difficult airway, aspiration risk) – if applicable
Fire Risk Assessment completed? (Verify each element scored & total score)

YesNo

If No, select the missing documentation (SELECT ALL THAT APPLY):

Documented confirmed patient identification and procedure (including site / side, as applicable) immediately prior to the procedure?

YesNo

If No, select the missing documentation (SELECT ALL THAT APPLY):

Patient Identification verifiedProcedure including site / sideNot completed immediately prior to start of procedure

Documented verified specimens labeled correctly, sponge / sharps /instruments count correct if utilized and key concerns for post procedure care & plan for safe hand-off and/or discharge verified with proceduralist?

YesNoN/A

If No, select the missing documentation (SELECT ALL THAT APPLY):

Verified specimens labeled correctlyVerified counts correct if sponge / sharps /instruments utilizedKey concerns for post procedure care & plan for safe hand-off and/or discharge verified with proceduralist

Comments:

Name of person completing audit:

First NameLast Name

Employee ID of person completing audit:

Moderate Sedation Audit Tool

PART 1: Physician Documentation

PART 2: Sedation Nurse Documentation

Immediate reassessment (R/A) documentation:

Intra-procedure sedation documentation:

Post-procedure sedation documentation:

Review each section of the UP checklist & confirm the following is documented:

PART 1: Pre-Procedure Verification of Time Out

PART 2: Time Out

PART 3: Post Procedure Verification