We have all heard that overhead announcement or received text messages and emails announcing their arrival. By that point it is too late to request a vacation day and there are no places to “hide” on the unit.
Here are a few tips to prepare you. They are based on a recent survey on the Sedation Unit at a local Children’s Hospital.
- Know how to “walk through” a patient’s medical record. In particular, identify the presedation assessment and documentation that the patient was reassessed immediately prior to the administration of sedation. Look for the sedation consent, including explanation of risks/benefits of sedation.
- Note the presence of pain assessments pre, intra and post procedure, as well as following medication administration.
- The surveyor “loved” the Pediatric Sedation State scale!
- Make sure that the indications for medications match the documented clinical assessments.
- Look for documentation of notification to providers when needed. For example, provider orders a medication that the patient refuses or an ordered medication is not given because the patient condition is not appropriate (sedation adequate).
- There should be a complete post procedure note from both the proceduralist and the sedation provider.
Best of luck on your next announced (or unannounced) survey!