From the Desk of David T. Palmer, Esq. 

Effective sedation recordkeeping is crucial for ensuring patient safety and compliance with state regulations. While each state has its own unique requirements, here’s an overview of key recordkeeping requirements for sedation procedures.

Pre-Operative Evaluation

The American Dental Association (ADA) recommends conducting a focused physical evaluation to assess the patient’s readiness for sedation. This evaluation should include recording baseline vital signs such as weight, height, blood pressure, pulse rate, and respiration.

Personnel Requirements

At least one additional person trained in Basic Life Support (BLS) should be present alongside the dentist. With moderate or intravenous (IV) sedation, two additional trained individuals may be necessary. 

Monitoring and Documentation

The dentist, or a trained individual under the dentist’s supervision, must remain with the patient to monitor their condition until they meet discharge criteria. 

Monitoring should include:

  • Consciousness: Regular assessment of the patient’s level of sedation and responsiveness.
  • Oxygenation: Tracking oxygen saturation using pulse oximetry.
  • Ventilation: Observing chest movements, verifying respirations, and, if necessary, monitoring end-tidal CO2 levels, particularly for moderate sedation.
  • Circulation: Evaluating blood pressure and heart rate pre-operatively, intraoperatively, and post-operatively. Continuous ECG monitoring is recommended for moderate sedation levels.

A complete sedative record should be maintained, including details such as vital signs, the names of all administered drugs, the times they were given, and their routes of administration.

Recovery and Discharge

The dentist must ensure and document that the patient’s levels of consciousness, oxygenation, ventilation, and circulation are satisfactory before discharge. This final assessment is crucial for confirming that the patient is stable and ready to safely leave the care setting.

It’s important you are familiar with the unique requirements in your state. If you have questions about the recordkeeping requirements in your state, please contact [email protected]

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