PROCEDURE FOR DOCUMENTATION OF SEDATION IN CCTC

Documents:


1.    24 hour - Nursing Assessment Record.
2.    Assessment and Intervention Record.
3.    Graphic record.
4.    Medication Administration Record.
Procedure
 Rationale
1. Establish patient specific Ventilation Adjusted Motor Assessment Scoring Scale (VAMASS) as per scoring tool. 

1. To provide an objective evaluation of the level of sedation. 

 
 
 
Procedure
Rationale
2.
Assess patient and determine the patient's VAMASS score.
2.
 To evaluate patient's level of sedation and compare to VAMASS goal.
3.
At the start of each day shift, record the following information under the "OTHER" section of the 24-hour assessment record as shown below:
  • the VAMASS goal
  • the observed VAMASS at the time of the assessment
  • plans for achieving the desired goal
3.
 To provide a record of the sedation goal, sedation score, and plans to achieve the goal.  This provides the basis for the 24 hour charting by exception.

To communicate to members of the team. 
4. Enter "sedation" as a parameter on the Assessment and Intervention flow sheet.  If the charted "plan" maintains the target VAMASS, arrow q4h as per other parameters.

If the plan requires modification or the patent varies significantly from the goal, complete a DAR note (e.g. additional sedation is ordered to achieve the target VAMASS; large doses of sedation are used during a procedure that causes increased sedation).

Note that sedation is a different parameter than "neuro".
 

 4. As per protocol for "charting by exception". 

Neurological assessment still needs to be performed to identify any focal or neurological findings.
5. Determine the patients "average" VAMASS score for the hour and chart on the graphic record as shown below:

Note: 
Nursing discretion is used to determine the frequency for charting on the graphic record.  If hourly or continuous infusions of sedation are being administered, the VAMASS should be charted hourly.  If the patient is very comfortable and requires little or no sedation, chart the VAMASS as per the minimum standards for DAR charting (q 4 h while awake).  The graphic should provide quick support for the amount of sedation that a patient is receiving.
 

 5. To document patient status. 

6. Each time that a prn dose of sedation is administered, record the patient's VAMASS score on the medication administration record.  Record the patient's score prior to receiving the medication.  6. To document rationale for administration of a prn medication. 

November 29, 2000
Revised: January 2001
BrendaMorgan, Clinical Educator, CCTC

LHSCHealth Professionals

Last Updated April 12, 2011 | © 2007, LHSC, London Ontario Canada