Question Moderate Conscious Sedation

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Hello everyone! We are getting some conflicting feedback regarding our documentation for conscious sedation. Currently, the note states:

"Moderate intravenous conscious sedation was supervised by Dr. ____________. The patient was independently monitored by a Registered Nurse using automated blood pressure, heart rate, and oxygen saturation. The detailed Registered Nursing Record is permanently stored in ____Our Practice name_____________ EMR. The following is the conscious sedation record: MEDS GIVEN 4 MG VERSED AND 200 MCG FENTANYL; FACE TO FACE TIME: 28 MINUTES."

Any feedback is appreciated. We were recently informed that the specific RN needs to be documented, and the face to face time does not satisfy the start and end time of the procedure.
 
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Clovis, CA
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I would say your documentation is inadequate as it does not say who performed the conscious sedation. Did the doctor do it? Did the RN do it? I only see "supervised by" and "monitored by".

I would also agree that the name of the RN needs to be documented.

I always tell people to document to the pickiest payer. That way, you don't have to remember who wants what. I also like start and stop times, because no one has extrapolated the total time (and perhaps done their math incorrectly).
 
Messages
3
Best answers
0
I would say your documentation is inadequate as it does not say who performed the conscious sedation. Did the doctor do it? Did the RN do it? I only see "supervised by" and "monitored by".

I would also agree that the name of the RN needs to be documented.

I always tell people to document to the pickiest payer. That way, you don't have to remember who wants what. I also like start and stop times, because no one has extrapolated the total time (and perhaps done their math incorrectly).

Thank you for taking the time to reply to this thread. We appreciate it!
 
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