Premier System Medical Executive Committee Update

By Marc Belcastro, DO, system chief medical officer, Premier Health

Periodically, we will utilize this forum to provide physicians and APPs with important information approved and/or discussed at the Premier System Medical Executive Committee. This month, I would like to highlight the privilege of providing moderate or deep sedation.

The language describing sedation has changed. Moderate and deep sedation is the preferred description as opposed to conscious sedation. This privilege has its own delineation of privilege form (DOP). In addition, this privilege is core (automatic) for anesthesiologists, emergency trained physicians, and critical care trained physicians. All other physicians wishing to exercise this privilege must request the DOP.

The main point of this update is to communicate the requirements around documentation.  Prior to the administration of moderate or deep sedation (except in an emergency such as rapid sequence intubation), a pre-sedation note is required to assess the patient’s risks, airway, and current medications to document the plan. After the procedure, as the patient begins to recover, a post-sedation note must be documented. This requirement is from the Joint Commission and is also found in our Rules and Regulations.

The names of the revised templates are the Moderate or Deep Sedation Pre-procedure Note and the Moderate or Deep Sedation Post-procedure Note. These are available as System Smart Phrases, or dot phrases. All other sedation templates have been removed, except for the pre- and post-anesthesia notes utilized by our anesthesia partners. You may type, “.seda” and press Enter. Double-click or highlight the desired template and press Enter to add the template into your note. These can also be added to your favorites by clicking the star to the left of the template. Read More.

Back to the July 2021 issue of Premier Pulse