Conscious Sedation Documentation

Editorial Team / Admin · Jun 20, 2005

mm65, I have been mulling over your post . . . we have a LITTLE bit of computer charting we do - basically a pre- and post- procedure template; it isn't the whole package -- it lacks VS and real-time comments. I'm not aware of any GOOD moderate sedation software available (but I'm not up on latest developments, either).

We are working on integrating our MacLab Hemodynamic monitoring to the hospital computer system, so we don't have to chart three places (paper, pre-and postprocedure in computer, as well as in MacLab).

My only (feeble) recommendation would be to ensure the charting meets JCAHO standards for moderate sedation documentation, whether paper or computer. Don't forget a place for the MDs to e-sign, for medication orders coverage. You'll want to meet with either your IT dept to coordinate this, or the vendor of the software you're going to use.

You might want to work with your anesthesia dept on this, or, better still, a multidisciplinary moderate sedation committee. I would think, at the very least, the anesthesia dept would be VERY interested in helping develop this documentation (they WILL be using it too, no?).

Good luck -- it's a process.

mwbeah · Jul 1, 2005

Hi
I'm a radiology rn and my facility is switching from paper to computer charting. We have to build documentation for our individual dept needs.
Does anyone out there have computerized documentation for conscious sedation and post conscious sedation???? If anyone does is it possible for you to send it to me so I have an idea of what it may look like and what I should include????????
Desperate, please help!!!!

More than likely your facility will be contracting out for that service, you may inquire to some health information systems company to see what they have.

Mike

suzanne4, RN · Jul 1, 2005

You essentially will be using what you have on paper, only converted for computer use. I suggest that you get the information that you wish to include and have it ready for when the switch is in progress, and your IT people can handle it.

What is included in the computer charting is not much different from what you are already doing on paper. Most of the IT people at your facility should be familiar to taking the piece of paper and translating it into a workable solution.