Moderate Sedation & documentation

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Hi, 

I haven't done this documentation yet, but I wanted to know do ER nurses have to do moderate sedation documentation for their patients who receive it (pre, intra and post documentation?)?

Are there any part of the documentation process for anything that takes a long time? For example blood admin and then there is a reaction, etc.  I wanted to be prepared so I don't have to interrupt anyone. Thank you. 

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Since I didn't get any replies I'll answer the question as I have looked it up. Yes, the nurse documents the moderate sedation. 

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Specializes in CEN, Firefighter/Paramedic.
delrionurse said:

Since I didn't get any replies I'll answer the question as I have looked it up. Yes, the nurse documents the moderate sedation. 

Sorry, I usually check this section more frequently.

Epic has a sedation tab and we use it in its entirety during sedation procedures (not including med assisted intubation).

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Specializes in ED & Critical Care CEN, TCRN, CCRN, CFRN, CTRN.

Sorry, I just saw this. I use the sedation narrator basically everyday. I do lots of moderate sedation documentation due to my dual role (ED and Preop Nerve block team). Honestly, the most time is taken in the pre procedure documentation (arriving the staff, time out, mod aldrete score, etc) the intra, medication admin, and post precudure is easy. My advice is to cycle cuff/vitals q3, and keep track of your times on scrap paper. Sometimes procedures can be so quick that, it's over before you finish the pre-procedure stuff. Also, be vigilant and keep an eye on the spo2 and Etco2. I've had patients crash on just 1 versed, and 50 mcg of fent.....

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