Conscious Sedation Recording Requirements & Aftercare

Standards in Conscious Sedation for Dentistry

Posted on the DSTG website September 26, 2012 by admin,

Originally Published: October, 2000.

Here is a useful resource especially if you have been undertaking dental conscious sedation for some years.

" Records and Documentation

 The most accurate, contemporaneous record of the consent process is the clinical record card.

It is recommended that a clinical record for conscious sedation should include the reason for Conscious Sedation and evidence of the consent process. The consent process includes both sedation and the treatment to be provided including:

• Written medical history

• Previous dental history.

• Written instructions have been provided pre- and post-operatively.

• The presence of an accompanying adult.

• The patient has complied with pre-treatment instructions.

• The medical history has been checked and acted upon.

• Records of drugs employed, dosages and times given including site and method of administration.

• Previous Conscious Sedation / General Anaesthetic History.

• Pre-sedation assessment.

• Any individual specific patient requirements.

• Suitable supervision has been arranged.

• There is written documentation of consent for sedation (Consent Form).

• Records of monitoring techniques.

• Full details of dental treatment provided.

• Post sedation assessment.

Aftercare

 Recovery

 Recovery from sedation is a steady progression from completion of treatment through to discharge into the care of an escort. The first stage of recovery is normally in the dental chair. Once the patient is recorvered sufficientyl to move to a resting area, they should be carefully guided and supported. This recovery area should be serparate from the main waiting room and contain furniture and firments for the comfort and well being of the patient.

A member of the dental team should supervise the patient during this period. Equipment and drugs for dealing with medical emergencies must be available. The dentist or sedationist must be available to see the patient urgently to deal with any problems that may arise.

 Discharge

 The decision to discharge a patient into the care of the escort following any type of sedation must be the responsibility of the dentist or the sedationist. The patient must have a responsible adult as an ascort. The criteria for discharge are that the patient should be able to walk unaided without stumbling or feeling unstable.

Aftercare Instructions

 In addition to specific instructions given to the patient and escort regarding the sedation, details of the dental treatment provided should be given to patient and and escort including any aftercare arrangement relating to pain control and possible postoperative bleeding. Adequate information including how to contact the dentist if necessary must be given.

I hope this has been a useful reminder. These parameters can be programmed into a computerised practice management system, so that that a simple series of tick boxes and some text input boxes, allows for rapid data entry by the practitioner or trained DN to conform to these requirements.

Required vCPD for Conscious sedation techniques

An additional reminder.
In 2011, the CPD requirements for everyone undertaking conscious sedation in dentistry were published and the recommendations are that 12 hours of vCPD should be undertaken every 5 years, for EACH technique being undertaken.
Full details ..

If you are already offering Inhalation Sedation and are interested in a 1/2 day refresher/update in Inhalation Sedation for your team or yourself 

please e-mail richard@the-ra-coach.co.uk