Amalgam vs. Composite: Filling in the Blanks

The first of a two-part series providing information and resources to keep your practice efficient and compliant in record keeping for sedation dentistry.

By Genni Burkhart Print & Go Guidance

In today’s competitive dental landscape, continuously strengthening your skills and knowledge is vital to scale your dental practice. By adding oral sedation dentistry or IV sedation dentistry to the services you provide, you can widen your patient reach and enable meaningful growth within your business. While there is some added responsibility placed on the dentist, as long as you and your staff are properly trained, carefully screen patients before administering medications, and maintaining accurate records, sedation dentistry can become a routinely practical skill that will benefit both you and your patients.

The addition of sedation dentistry to your practice does add another layer of compliance to your record keeping, as the DEA mandates each “registrant” who possesses controlled substances maintain complete and accurate records. However, DOCS Education is here to help by offering sedation education, training, and resources that will keep your practice organized, efficient, and compliant.

In this, the first of a two-part series aimed at taking the mystery out of sedation dentistry record keeping, we’ll provide print and go guidance on obtaining a DEA license and the requirements for sedation dentistry records. In the next article we’ll review best practices for recording and dispensing of controlled substances, guidelines for storing controlled substances, and the proper handling of expired drugs.

First Step: Obtain a DEA License

To administer controlled substances as a sedation dentist, you must first register with the DEA. Important factors in obtaining a DEA license include:

  • The DEA provides a manual that specifically lays out the requirements of record keeping, storage, and inventory for the prescribing and dispensing of controlled substances.

  • The cost of registration is $731 every three years.

  • Getting an account set up can take a few weeks. Be patient and take a systemic approach to this step well before you plan on ordering and dispensing medications.

  • When registering with the DEA, plan on approximately 6 weeks for the entire process.

  • Tip: To avoid further delays, when filling out all paperwork from the start, be sure the DEA license and office address match the dental license address.

  • Send copies, not originals. You won’t get them back.

After you have a DEA account, you’re now able to order sedation medications. Sedation medications in the anxiolysis protocols are schedule IV substances. Inventory records for these controlled substances must be maintained and on site for two years per DEA regulations.

Why Keep Sedation Dentistry Records?

Accurate documentation for sedation must be kept on site for regulations, laws, licensing, and avoidance of fines. By utilizing practical ways to incorporate efficient, effective, and proper documentation of patient care, dentists honor their obligation to do no harm to the patient, as accurate record keeping is part of responsible care.

As a sedation dentist, the main components of accurate, compliant, and complete records should include:

  • The pre-sedation evaluation: Dental, physical and emotional parameters, medication administration.

  • Drug storage, dispensing and disposal of controlled substances. Administration of stocking inventory.

  • End of appointment summary and disposition, oriented by 3, companion information, post-operative instructions, and proper release.

Clinical Record Keeping

The following is an easy-to-follow checklist and flow of item needed for sedation record keeping. Sedation dentistry records need to include the following:

  • Pre-Sedation Paperwork Includes:

    • Medical history.

    • Completed emotional/dental exam forms.

    • Need for Sedation determined/dental treatment plan accepted.

    • Baseline vitals obtained.

    • Social History (smoking, drinking, recreational drug history).

    • Informed consent.

    • Dental treatment plan accepted and need for sedation determined.

  • Before/After Instructions:

    • Review with patient prior to and after sedation appointment.

    • Provide patient with instructions day before and day of appointment.

  • Keep all Records of Dispensing Controlled Substances to Patient In:

    • Comprehensive chart notes.

    • Procedures performed.

    • Sedative meds dispensed.

    • Dosage, times, and routes of administration of all medications and local anesthetics used.

    • Disposition of patient at arrival, during sedation, and at dismissal.

  • Carpule Count Sheet:

    • List procedure(s) preformed.

    • List each type of anesthetic given and include time administered.

    • Printout from pulse oximeter should be copied and remain part of permanent record.

    • 3 vital sign readings from pulse oximeter. Record manually during appointment and recorded on standard anesthesia form.

    • Oral sedation binders (for those who are DOCS trained).

    • Complete notes after exam.

  • Required Equipment for Sedation Includes:

    • Companion chair.

    • Emergency oxygen. Inspect oxygen tanks weekly, document, and keep those records onsite.

  • Flow of Efficient Record Keeping:

    • Organization: Intake and drug reconciliation done by the ordering assistant, train dispensing team members as reconciliation assistants.

    • New Patient Exam: health history, med review, social history, consent, instructions, treatment, plan by doctor, and payment by front office.

  • Sedation Visit:

  • Dental assistant records, dentist reviews for accuracy, dentist assistant logbooks. Log all drugs and waste, ride home instructions, and scan paperwork into chart.

If you have further questions or would like to learn more about sedation dentistry for your dental practice, or want to obtain CE credits visit DOCS education for courses, resources, products, home study, and membership. DOCS members also have the added benefit of consulting our legal counsel on various issues related to sedation dentistry. In the next issue of the Incisor we’ll continue to take the mystery out of drug storage, dispensing and disposal of controlled substances.

Author: With over 10 years as a published journalist, editor, and writer Genni Burkhart’s career has spanned across politics, healthcare, law, business finance, and news. She resides on the western shores of the Puget Sound where she works as the Editor in Chief at DOCS Education out of Seattle, WA.

The information contained in this, or any case study post in Incisor, should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 3250 Airport Way S, Suite 701 | Seattle, WA 98134. Please print a copy of this posting and include it with your question or request.
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