The Sedation Pre-Assessment Notes Template

Failing to document ASA classification and airway assessment is a serious record gap if adverse events occur during sedation. Below is a template for UK sedationists to paste into their PMS for every sedation pre-assessment.

Why this sedation pre-assessment template wins

• ASA classification documented EXPLICITLY — a key defensive entry 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.

The template (paste into your PMS notes field)

Paste the sedation pre-assessment 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)

REASON FOR SEDATION REQUEST: [Anxiety / procedure complexity / patient request / paediatric]

ANXIETY ASSESSMENT:
- MDAS score: [/25 — administer questionnaire]
- Or DAS score: [/20]
- Specific fears: [Needles / drilling / smells / loss of control]
- Previous anxiety management: [Worked / not worked]

DENTAL TREATMENT PLANNED: [Specific procedures + estimated duration]

FULL MEDICAL HISTORY:
- Cardiovascular: [Heart disease / hypertension — BP today / arrhythmias]
- Respiratory: [Asthma — control / COPD (contraindication for N2O) / sleep apnoea (OSA — caution with IV sedation)]
- Endocrine: [Diabetes / thyroid / adrenal]
- Neurological: [Epilepsy / stroke / dementia]
- Renal / hepatic: [Function — affects drug metabolism]
- Psychiatric: [Medications (e.g. benzodiazepine tolerance / antidepressants / antipsychotics)]
- Pregnancy / BF: [N/A / trimester / breastfeeding consideration]
- ALLERGIES: [NKDA / specific — sedative allergies particularly]

ASA CLASSIFICATION:
- ASA I (healthy) / ASA II (mild systemic disease, controlled) / ASA III (severe systemic disease — many need referral to secondary care; some may be treated in primary care depending on facilities, skills and stability) / ASA IV (refer to secondary care) — SDCEP 3.2
- Rationale: [Documented]

CURRENT MEDICATIONS:
- List all
- Specific interaction checks with sedatives (BNF reviewed):
  - Benzodiazepines / opioids: [Synergistic with midazolam — adjust dose]
  - Antipsychotics: [Caution]
  - Antiepileptics: [Hepatic interactions]
  - Beta-blockers: [Caution with hypotension]
  - Anticoagulants: [Cross-reference for surgical procedure]

AIRWAY ASSESSMENT:
- Mallampati score: [I / II / III / IV — Class III/IV indicates difficult airway, caution]
- Mouth opening: [mm — adequate / restricted]
- Neck mobility: [Full / restricted]
- Thyromental distance: [Estimated]
- Dentition: [Loose teeth / crowns at risk]

BMI:
- Height: [cm]
- Weight: [kg]
- BMI: [calculated — SDCEP ASA examples: obesity (BMI 30-40) = ASA II; BMI ≥40 = ASA III]

SOCIAL HISTORY:
- Smoking: [Status]
- Alcohol: [Units/week — relevant for chronic alcohol use altering drug metabolism]
- Recreational drugs: [Affects drug response]
- Escort plan: [Confirmed adult escort, supervision overnight]
- Childcare arrangements: [If parent of young children]

TECHNIQUE SELECTED:
- [IV midazolam / inhalation N2O / oral midazolam]
- Rationale: [Anxiety level + procedure complexity + patient factors]

WRITTEN CONSENT (sedation-specific):
- Procedure explained
- Risks discussed: paradoxical reaction (especially midazolam), over-sedation, allergic reaction (rare), respiratory depression, prolonged drowsiness
- Alternatives: GA hospital referral, behavioural management alone, no treatment
- Post-procedure restrictions explained (24h for IV)
- Written consent SIGNED today (or at sedation appointment if pre-assessment separate)

APPOINTMENT PLANNED:
- Date / time: [Specified]
- Fasting advice given: [None / light meal / 2-4-6 — reason recorded] (individual assessment — SDCEP 3.5)
- Pre-procedural medication review: [E.g. continue antihypertensives, hold metformin morning of for IV]

Try the sedation pre-assessment note in the live demo → No account needed.

What good looks like — a worked example

The same sedation pre-assessment template, completed for a realistic case.

REASON FOR SEDATION REQUEST: Severe dental anxiety, patient unable to tolerate routine treatment. Requires multiple extractions.

ANXIETY ASSESSMENT:
- MDAS score: 22/25 (very high — severe dental anxiety)
- Specific fears: Needles, drilling sounds, loss of control during procedure
- Previous: Has avoided dental care for 8 years. Past attempts at routine treatment unsuccessful (panic attack at chair).

DENTAL TREATMENT PLANNED: Extraction UR6, UR7, UL6 (caries non-restorable). Estimated 45-minute procedure.

FULL MEDICAL HISTORY:
- Cardiovascular: No heart disease. BP 128/76. No arrhythmias.
- Respiratory: Asthma — well-controlled, salbutamol PRN, last attack 6 months ago. No COPD. No OSA.
- Endocrine: None.
- Neurological: None.
- Renal / hepatic: Normal function (no medications affecting).
- Psychiatric: Mild depression — sertraline 50mg OD (SSRI). NO benzodiazepine current use. NO antipsychotics.
- Pregnancy: N/A (male).
- Allergies: NKDA.

ASA CLASSIFICATION: ASA II (mild systemic disease — asthma well-controlled, mild depression on stable SSRI).
- Rationale: Both conditions stable, not impacting functional status. Standard sedation appropriate; specialist setting not required.

CURRENT MEDICATIONS:
- Salbutamol inhaler 100mcg PRN (rare use)
- Sertraline 50mg OD
Interaction checks (BNF):
- Sertraline + midazolam: minimal interaction. SSRIs generally compatible with single-dose benzodiazepines.
- No anticoagulants. No opioids. No benzodiazepine tolerance.

AIRWAY ASSESSMENT:
- Mallampati: Class II (good visualisation)
- Mouth opening: 50mm (excellent)
- Neck mobility: Full
- Thyromental distance: Adequate
- Dentition: No loose teeth. No crowns at airway risk.

BMI:
- Height: 178cm
- Weight: 82kg
- BMI: 25.9 (overweight range, 25 to 29.9)

SOCIAL HISTORY:
- Smoking: Non-smoker
- Alcohol: 10 units/week (within recommended limits)
- Recreational drugs: None
- Escort plan: Wife will collect, supervise overnight, take time off work next day to assist
- Childcare: Not applicable

TECHNIQUE SELECTED: IV midazolam sedation
- Rationale: Severe anxiety (MDAS 22/25) + multiple extractions + previous failure of behavioural approaches. IV provides reliable sedation level. Patient ASA II, no contraindications, adequate airway, suitable escort plan.

WRITTEN CONSENT:
- Procedure explained including each extraction + sedation
- Risks discussed: paradoxical reaction (rare with midazolam), over-sedation, respiratory depression (monitored), allergic reaction (very rare), prolonged drowsiness, post-op nausea, awareness of procedure (patient may remember parts)
- Alternatives: GA hospital referral (waiting list 6+ months, more invasive); behavioural management alone (failed previously); leave extractions (caries progresses, eventual emergency)
- Post-procedure: NO driving / decision-making / alcohol 24h; rest required; escort essential
- Written consent SIGNED today (specific sedation consent form on file)

APPOINTMENT PLANNED:
- Date: 2 weeks from today
- Time: 09:00
- Fasting: No indication for fasting — advised to eat and drink normally on the day, avoiding alcohol and large meals (SDCEP 3.5). Written instructions provided.
- Pre-procedural: Continue salbutamol if needed. Continue sertraline as normal. No specific medication holds required.

Compliance: the medico-legal angle

• IACSD Standards V1.1 (2020) — pre-assessment requirements.
• SDCEP Conscious Sedation in Dentistry (3rd ed, June 2017; reviewed and unchanged December 2022) — 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 documentation mistakes

• ASA grade not documented — indefensible if adverse event.
• Airway not assessed — record Mallampati, mouth opening and neck mobility; they inform whether primary care is the right setting.
• 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.

Sources

• GDC Standards for the Dental Team, Principle 3: Obtain valid consent (accessed 18 October 2026)
• Montgomery v Lanarkshire Health Board (UK Supreme Court, 2015, UKSC 11) (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

• Your Guide to Dental Sedation
• Preparing for Your Dental Surgery
• After Your Dental Sedation

Related dental note templates

Browse the full set of free dental notes templates.