HKL/BPK/PED/URH/102

CHECKLIST PRIOR TO SEDATION FOR NUCLEAR MEDICINE PROCEDURE

(MUST BE FILLED UP BY MEDICAL OFFICER REQUESTING THE PROCEDURE)

PATIENT’S NAME : ………………………………………………………………….....

I/C NUMBER (PATIENT) : …………………………………………………………………….

AGE : …………………….. WT : ……………….HT : …………………

DIAGNOSIS : …………………………………………………………………….

HOSPITAL/DEPARTMENT/UNIT : …………………………………………………………………

I II III IV V
STATE ASA CLASSIFICATION (refer table)

1. Did patient undergo any procedure that requires sedation previously? YES/NO

2. If yes, state what is the procedure and when was it done? List down all.
……………………………………………………………………………………………..
……………………………………………………………………………………………..

3. History of previous sedation ; -

a) Any difficulty / problem with previous sedation? YES/NO
b) If yes, state what was it ; -
………………………………………………………………………………………….
c) What types of sedation given? Name it and please state ORAL/ IV / GA.
CAUTION : IF PATIENT’S NEED GA FOR ANY IMAGING PROCEDURE
PREVIOUSLY, PLEASE ADMIT PATIENT TO RESPECTIVE WARD ONE DAY
BEFORE PROCEDURE.

4. Any history of cardio respiratory collapse with sedation. YES/NO

Action taken then : ……………………………………………………………………..
…………………………………………………………………………………………..

5. History of allergic to ; - YES/NO

a) Food : ………………………………………………………………………………
b) Sedation : ………………………………………………………………………………
c) Any other drugs : ……………………………………………………………………...

6. History of Asthma. YES/NO

7. Name of Requesting Doctor’s : …………………………………………………….

Signature : …………………………………………………….
Contact Number ` : …………………………………………………….

KOI/P00/2014