The Sedation Pre-Assessment Notes Template
A sedation pre-assessment notes template captures the consultation BEFORE sedation — dental anxiety score (MDAS/DAS), full medical history with ASA classification, current medication interactions with sedative agents, airway assessment (Mallampati, mouth opening), BMI calculation, social history confirming escort and supervision, written consent for sedation, and technique selection rationale — meeting IACSD Standards V1.1 (2020) and SDCEP Conscious Sedation in Dentistry (3rd ed, 2022 surveillance review).
Failing to document ASA classification and airway assessment is the single most indefensible record gap if adverse events occur during sedation. Below is the template UK sedationists paste into their PMS for every sedation pre-assessment.
Download the free Sedation Pre-Assessment template — plain text, GDC/FGDP(UK)-aligned.
Why this sedation pre-assessment template wins
- ASA classification documented EXPLICITLY — single most indefensible gap if adverse events occur.
- Airway assessment (Mallampati, MO, neck) — defends sedation safety.
- BMI calculated — drives sedation dosing and risk.
- Drug interaction check against current medications — defends safe drug selection.
- Escort and supervision plan — IACSD compliance for IV sedation.
Compliance: the medico-legal angle
- IACSD Standards V1.1 (2020) — pre-assessment requirements.
- SDCEP Conscious Sedation in Dentistry (3rd ed, 2022 surveillance) — ASA + airway + interactions assessment.
- GDC Principle 3 — sedation is an additional procedure requiring its own consent.
- Montgomery — sedation-specific risks (over-sedation, paradoxical, awareness) must be discussed.
Common mistakes UK dentists make
- ASA grade not documented — indefensible if adverse event.
- Airway not assessed — high BMI / Mallampati III/IV patients should not have routine sedation in primary care.
- Drug interactions not checked — particularly relevant for psychiatric medications.
- Escort plan not documented — patient discharged to home alone post-sedation = liability.
- Sedation consent same form as procedure consent — should be separate, sedation-specific.
Frequently asked questions
What ASA grades can I sedate in primary care?
IACSD: ASA I and II suitable for primary care conscious sedation. ASA III requires specialist setting (hospital or specialist sedation centre). ASA IV/V — not appropriate for conscious sedation outside intensive care. Document the grade and basis.
How do I score Mallampati?
Patient sitting upright, mouth wide open, tongue protruded. Class I: full uvula and tonsils visible. Class II: uvula partly visible. Class III: only soft palate visible (difficult airway). Class IV: only hard palate visible (very difficult airway). Class III/IV indicates caution / specialist setting.
BMI cutoff for primary care sedation?
IACSD: BMI >35 triggers additional consideration. BMI >40 (morbid obesity): specialist setting strongly recommended due to airway risks, sedative pharmacokinetics, and OSA risk. Document the BMI and decision.
Do I need separate sedation consent?
Yes — sedation is an additional procedure beyond the dental work. Consent must cover: drug used, technique, risks (paradoxical, over-sedation, respiratory depression, awareness), alternatives (GA, no sedation), post-procedure restrictions, escort requirement. Signed and dated.
When should I refer for GA instead of sedation?
Failed previous sedation attempts, ASA III+, severe airway challenge (Mallampati IV, severe trismus), very young children requiring extensive treatment, complex behavioural / cognitive issues (e.g. severe autism, severe learning disability needing GA for completion), severe OSA. Document the rationale.
How long between pre-assessment and sedation appointment?
Typically 1-4 weeks — long enough to arrange escort and prepare, short enough that MHx remains current. Re-confirm MHx changes at sedation appointment.