The IV Conscious Sedation Notes Template

IACSD requires CONTEMPORANEOUS documentation of every drug dose and monitoring parameter — incomplete monitoring logs are indefensible if adverse events occur. Below is a template for UK sedation clinicians to paste into their PMS for every IV sedation case.

Why this IV conscious sedation record template wins

• Contemporaneous drug administration log with timestamps — IACSD MANDATORY.
• Clinical, SpO2 and NIBP monitoring log pre-, intra- and post-op (IACSD 2020 Table 2) — adverse event defensibility.
• Discharge criteria checklist — every box must be ticked; defends against post-discharge complications.
• Written + verbal post-op instructions to ESCORT, not just patient — patient is impaired by sedation.
• Aldrete score progression in recovery — quantifies fitness for discharge.

The template (paste into your PMS notes field)

Paste the IV conscious sedation record template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.

STANDARD VERSION CITED: IACSD Standards for Conscious Sedation in the Provision of Dental Care V1.1 (2020); SDCEP Conscious Sedation in Dentistry 3rd ed (June 2017, reviewed and unchanged December 2022)

SEDATION TYPE: IV conscious sedation — midazolam (standard technique)
[Propofol and drug combinations (e.g. opioid + midazolam) are advanced techniques (SDCEP 4.2) with additional staffing, training and facility requirements — a dedicated sedationist is required for propofol target-controlled infusion and propofol with midazolam. Use a separate advanced-technique record.]
INDICATION: [Dental anxiety MDAS score / specific procedure / patient request]

PRE-SEDATION CHECKS:
- MHx reviewed: [No new changes since pre-assessment]
- ASA grade: [I / II / III — many ASA III patients need referral to secondary care; some may be treated in primary care depending on facilities, skills and stability (SDCEP 3.2). ASA IV — refer to secondary care]
- Fasting advice given at assessment: [None / light meal / 2-4-6 — reason] — food and fluid intake today confirmed and recorded
- Escort present: [Name / contact / will collect at discharge / responsible adult overnight]
- Written consent: [Reviewed and signed today / re-confirmed from pre-assessment]
- Allergies confirmed: [NKDA / specific]

BASELINE OBSERVATIONS (pre-sedation):
- SpO2: [%]
- BP: [/ ]
- Heart rate: [bpm]
- Respiratory rate: [/min]
- Time:

CANNULATION:
- Site: [Vein — typically dorsum of hand / antecubital fossa]
- Cannula: [Size — typically 22G/20G]
- Patency confirmed: [Saline flush]

DRUG ADMINISTRATION LOG (contemporaneous timestamps — MANDATORY per IACSD):
Drug 1: Midazolam — [batch number / expiry]
  - Time __:__   Dose __mg   SpO2 __%   HR __   BP __/__
  - Time __:__   Dose __mg   SpO2 __%   HR __   BP __/__
  - Total dose: __mg

DENTAL TREATMENT (concurrent with sedation): [Procedure performed — cross-reference to clinical note]

INTRA-OPERATIVE MONITORING LOG (IACSD 2020 Table 2 — IV midazolam: clinical, pulse oximetry and NIBP):
- Clinical signs + SpO2 continuously; NIBP at intervals appropriate to the patient and technique; record contemporaneously and at every significant event
- Time __:__   SpO2 __%   HR __   BP __/__  Clinical: [Depth of sedation / airway / respiration]  Note: [Procedure milestone / re-dose / patient response]
- Time __:__   SpO2 __%   HR __   BP __/__  Clinical:   Note:
- Time __:__   SpO2 __%   HR __   BP __/__  Clinical:   Note:

RECOVERY:
- Time sedation ended: __:__
- Recovery monitoring: continued
- Aldrete / recovery score at 5-minute intervals
- Post-operative NIBP: __/__ (time __:__)
- SpO2 / HR / BP on discharge: __% / __ / __/__

DISCHARGE CRITERIA (ALL must be met before discharge):
- Patient ambulatory with support: [Y]
- Vital signs stable: [Y]
- Escort present: [Y — name confirmed]
- Verbal post-op instructions given: [Y]
- WRITTEN COPY of post-op instructions given: [Y]
- 24-hour emergency contact provided: [Y]
- Aldrete score ≥9 (or equivalent): [Y]
- Time of discharge: __:__

POST-PROCEDURE:
- Follow-up / review: [If arranged — date / method]
- Emergency contact provided: [Y]
- Driving / decision-making / alcohol warnings given (24h): [Y]

Try the IV conscious sedation record note in the live demo → No account needed.

What good looks like — a worked example

The same IV conscious sedation record template, completed for a realistic case.

SEDATION TYPE: IV conscious sedation — midazolam
INDICATION: Dental anxiety MDAS 22/25 (high). Patient requires multiple extractions UR + UL quadrants today.

PRE-SEDATION CHECKS:
- MHx reviewed: No changes since pre-assessment. Asthma well-controlled (salbutamol PRN). No other conditions.
- ASA grade: II (mild lung disease — well-controlled asthma)
- Fasting: Advice at assessment — no indication for fasting; eat and drink normally, avoiding alcohol and large meals (SDCEP 3.5). Today: light breakfast 07:00, water 08:00. Confirmed and recorded.
- Escort: Husband (Mr Patel) present in waiting room with car, will collect and stay with patient overnight.
- Written consent: Reviewed today, patient initialled refresh. Consent for sedation + extraction procedure on file.
- Allergies: NKDA confirmed.

BASELINE OBSERVATIONS (09:15):
- SpO2: 99%
- BP: 128/76
- Heart rate: 78bpm
- Respiratory rate: 16/min

CANNULATION:
- Site: Dorsum of left hand, vein visible
- Cannula: 22G BD Insyte
- Patency: 5ml saline flush — no resistance, no extravasation

DRUG ADMINISTRATION LOG:
Midazolam (Hypnovel 5mg/5ml ampoule) — batch [MID-2026-04-789] expiry 2027-06
  - 09:20   Dose 2mg   SpO2 99%   HR 76   BP 126/78   (initial titration)
  - 09:24   Dose 1mg   SpO2 99%   HR 74   (titrating to effect)
  - 09:28   Dose 1mg   SpO2 99%   HR 72   (verbal contact maintained, drowsy, eyes closed)
  - 09:32   Dose 0.5mg   SpO2 99%   HR 70   BP 118/72   (final titration — Verrill's sign achieved)
  - Total midazolam dose: 4.5mg

DENTAL TREATMENT: Extraction UR6, UR7, UL6 (cross-reference extraction note). LA: articaine 4% w/ adrenaline 1:100,000, 5.1ml total over the three teeth.

INTRA-OPERATIVE MONITORING LOG:
- 09:35   SpO2 99%   HR 72   BP 116/72   Responds to voice, airway clear, RR 14   Procedure commenced (UR6 LA)
- 09:40   SpO2 99%   HR 70   UR6 extraction in progress
- 09:45   SpO2 99%   HR 68   BP 114/70   UR6 delivered, UR7 commenced
- 09:50   SpO2 99%   HR 68   UR7 delivered
- 09:55   SpO2 99%   HR 70   BP 118/72   UL6 LA
- 10:00   SpO2 99%   HR 72   UL6 in progress
- 10:05   SpO2 99%   HR 72   BP 120/74   UL6 delivered, sutures placing
- 10:10   SpO2 99%   HR 74   Sutures complete, procedure ended

RECOVERY:
- Time sedation ended: 10:10 (no more drug given after this)
- Recovery monitoring: continued in recovery area with nurse
- 10:15: Patient drowsy, responsive to voice. SpO2 99% HR 74 BP 120/74. Aldrete 7
- 10:25: Patient alert, responsive. SpO2 99% HR 76. Aldrete 9
- 10:35: Patient fully alert, conversational. SpO2 99% HR 78 BP 124/76. Aldrete 10
- SpO2/HR/BP on discharge: 99% / 78 / 124/76

DISCHARGE CRITERIA (10:40):
- Patient ambulatory with support: Y (husband walking with her)
- Vital signs stable: Y
- Escort present: Y (Mr Patel)
- Verbal post-op instructions given: Y
- WRITTEN COPY of post-op instructions given: Y (extraction aftercare leaflet)
- 24-hour emergency contact provided: Y (practice number + out-of-hours)
- Aldrete score: 10
- Time of discharge: 10:45

POST-PROCEDURE:
- Follow-up: nurse phone call tomorrow morning (practice protocol)
- Emergency contact provided: practice number + out-of-hours / A&E criteria explained
- Driving / decision-making / alcohol warnings: 24h prohibition explained verbally and in writing. Husband acknowledged supervision plan.

Compliance: the medico-legal angle

• IACSD Standards for Conscious Sedation in the Provision of Dental Care V1.1 (2020) — the primary UK reference.
• SDCEP Conscious Sedation in Dentistry (3rd ed, June 2017; reviewed and unchanged December 2022).
• GDC Principle 4 — sedation records must enable continuation of care and adverse event review.
• Drug traceability — batch + expiry per dose for MHRA medicines stewardship.

Common documentation mistakes

• Drug doses recorded without timestamps — IACSD breach.
• No blood pressure after baseline — IACSD 2020 (Table 2) and SDCEP (4.3) require NIBP pre-, intra- and post-operatively for IV midazolam.
• Discharge before all criteria met — patient adverse event in car park or at home.
• Verbal-only post-op instructions to sedated patient — patient won't remember; escort must receive written copy.
• Propofol or drug-combination sedation recorded on a standard operator-sedationist record — these are advanced techniques (SDCEP 4.2) with additional staffing and training requirements.

Sources

• GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (accessed 18 October 2026)
• SDCEP: Conscious Sedation in Dentistry (3rd edition, June 2017; reviewed and unchanged December 2022) (accessed 18 October 2026)
• IACSD: Standards for Conscious Sedation in the Provision of Dental Care (2015, updated March 2020) (accessed 18 October 2026)

Frequently asked questions

Patient leaflets for this treatment

• After Your Dental Sedation
• Your Guide to Dental Sedation

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