Forms and Documentation
Comprehensive documentation is paramount in sedation practice, serving as a cornerstone for regulatory compliance, quality assurance, risk management, and seaml
Introduction to Sedation Documentation
Comprehensive documentation is paramount in sedation practice, serving as a cornerstone for regulatory compliance, quality assurance, risk management, and seamless continuity of care. The intricate nature of sedation services necessitates highly detailed records that systematically capture patient assessment, meticulous treatment planning, precise procedure execution, real-time monitoring data, and overall outcomes. This level of thoroughness is crucial for maintaining a legally defensible record, as highlighted by reference [134].
Effective sedation documentation strikes a crucial balance between comprehensiveness and practicality. It is designed to ensure all required information is meticulously captured without imposing an undue administrative burden that could detract from direct patient care. The documentation systems and forms outlined within this chapter have been specifically developed to streamline the documentation process, thereby ensuring comprehensive coverage of all essential elements.
These documentation tools are intended to be adaptable. Practices should customize them to align with their unique operational needs, specific state regulatory requirements, and individual workflow preferences. This customization, however, must always uphold the comprehensive approach vital for ensuring safe and effective sedation practice. Adhering to these principles ensures that documentation supports, rather than hinders, the delivery of high-quality patient care.
Key Points
- Comprehensive documentation represents one of the most critical aspects of sedation practice, serving multiple essential functions including regulatory compliance, quality assurance, risk management, and continuity of care
- The complex nature of sedation services requires detailed documentation that captures patient assessment, treatment planning, procedure execution, monitoring data, and outcomes in a systematic and legally defensible manner \[134\]
- Effective sedation documentation must balance thoroughness with practicality, ensuring that all required information is captured without creating excessive administrative burden that could interfere with patient care
- The documentation systems and forms presented in this chapter are designed to streamline the documentation process while ensuring comprehensive coverage of all essential elements
- These documentation tools should be customized to meet specific practice needs, state regulatory requirements, and individual workflow preferences while maintaining the comprehensive approach necessary for safe, effective sedation practice
Patient Assessment and Consent Forms
For practices offering dental sedation, comprehensive patient assessment and consent documentation are paramount. A specialized medical history form for sedation patients systematically captures critical information, enabling the identification of potential risk factors and contraindications. This form includes patient demographics such as name, date of birth, age, primary physician, and phone number. It specifically screens for current medical conditions like heart disease, high blood pressure, diabetes, lung disease, and pregnancy. Additionally, it requires a detailed list of current medications (prescription, OTC, supplements) with dosage, frequency, and last taken date, along with any known allergies or adverse reactions, specifying the drug/substance, reaction type, and severity. The form also investigates previous anesthesia/sedation experiences, social history (tobacco, alcohol, recreational drug use, last use date), a review of systems (e.g., chest pain, shortness of breath, dizziness), family history of anesthesia problems (e.g., malignant hyperthermia), and an anxiety assessment, including a 1-10 scale rating and specific fears.
Beyond the medical history, a systematic physical examination is essential for thorough sedation planning and risk assessment. The Pre-Sedation Physical Examination form documents vital signs including blood pressure, pulse, respiratory rate, temperature, oxygen saturation, weight, height, and BMI. It assesses general appearance (well-appearing, anxious, distressed), and conducts detailed cardiovascular, respiratory, and neurological examinations, noting heart sounds, breath sounds, mental status, and gait. A critical component is the airway assessment, measuring mouth opening (normal >3 cm), Mallampati Class (I-IV), thyromental distance (normal >6 cm), neck extension, and dentition. Finally, the examiner assigns an ASA Physical Status Classification (ASA I-IV) and determines sedation appropriateness, indicating whether office-based sedation is suitable, if medical consultation is needed, if hospital-based care is required, or if sedation is contraindicated.
To ensure ethical practice and legal protection, comprehensive informed consent is indispensable. The Sedation Informed Consent Form confirms the patient's understanding of the recommended sedation type (Nitrous Oxide, Oral Sedation, IV Conscious Sedation, or other). It clearly outlines the benefits of sedation, such as reduced anxiety, increased comfort, efficiency in treatment completion, reduced memory of the procedure, and improved patient cooperation. Crucially, the form also addresses potential risks and complications, acknowledging that no medical or dental procedure is without inherent risks. This detailed documentation ensures patients are fully informed before proceeding with sedation.
Key Points
- A thorough medical history form specifically designed for sedation patients helps ensure that all relevant medical information is captured systematically while identifying potential risk factors and contraindications
- **Sedation-Specific Medical History Form**
DENTAL SEDATION MEDICAL HISTORY FORM
Patient Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_
Date of Birth: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Age: \_\_\_\_\_\_\_\_\_\_\_\_\_\_
Primary Physician: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Phone: \_\_\_\_\_\_\_\_\_\_\_
CURRENT MEDICAL CONDITIONS (Check all that apply):
□ Heart disease/murmur □ High blood pressure
□ Stroke □ Diabetes
□ Kidney disease □ Liver disease
□ Lung disease/asthma □ Sleep apnea
□ Seizure disorder □ Thyroid problems
□ Mental health conditions □ Pregnancy (possible/confirmed)
□ Bleeding disorders □ Allergies/reactions
□ Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
CURRENT MEDICATIONS (Include prescription, over-the-counter, and supplements):
Medication Name Dosage Frequency Last Taken
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
ALLERGIES AND ADVERSE REACTIONS:
Drug/Substance Type of Reaction Severity
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
PREVIOUS ANESTHESIA/SEDATION EXPERIENCE:
□ General anesthesia □ IV sedation □ Nitrous oxide
□ Local anesthesia only □ No previous experience
Describe any problems or complications:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
SOCIAL HISTORY:
Tobacco use: □ Never □ Former □ Current (\_\_\_\_\_ per day)
Alcohol use: □ Never □ Occasional □ Regular (\_\_\_\_\_ per week)
Recreational drug use: □ Never □ Former □ Current
Last use of alcohol/drugs: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
REVIEW OF SYSTEMS:
□ Chest pain/pressure □ Shortness of breath
□ Irregular heartbeat □ Dizziness/fainting
□ Frequent headaches □ Difficulty swallowing
□ Snoring/sleep problems □ Recent weight loss/gain
□ Nausea/vomiting □ Changes in appetite
FAMILY HISTORY OF ANESTHESIA PROBLEMS:
□ None known □ Malignant hyperthermia □ Other: \_\_\_\_\_\_\_\_\_\_
ANXIETY ASSESSMENT:
Rate your dental anxiety (1-10 scale): \_\_\_\_
Specific fears or concerns:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Patient Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_
Doctor Review: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_
Systematic physical examination documentation ensures that all relevant physical findings are assessed and recorded appropriately for sedation planning and risk assessment
- **Pre-Sedation Physical Examination Form**
PRE-SEDATION PHYSICAL EXAMINATION
Patient Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_
Examiner: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
VITAL SIGNS:
Blood Pressure: \_\_\_\_\_\_\_ / \_\_\_\_\_\_\_ mmHg Pulse: \_\_\_\_\_ bpm
Respiratory Rate: \_\_\_\_\_ /min Temperature: \_\_\_\_\_ °F
Oxygen Saturation: \_\_\_\_\_ % (room air) Weight: \_\_\_\_\_ lbs
Height: \_\_\_\_\_ ft \_\_\_\_\_ in BMI: \_\_\_\_\_
GENERAL APPEARANCE:
□ Well-appearing □ Anxious □ Distressed □ Other: \_\_\_\_\_\_\_
CARDIOVASCULAR EXAMINATION:
Heart Rate: □ Regular □ Irregular
Heart Sounds: □ Normal □ Murmur □ Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Peripheral Pulses: □ Normal □ Diminished □ Absent
Edema: □ None □ Present (location): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
RESPIRATORY EXAMINATION:
Respiratory Effort: □ Normal □ Labored □ Shallow
Breath Sounds: □ Clear □ Wheezes □ Rales □ Rhonchi
Chest Wall: □ Normal □ Abnormal (describe): \_\_\_\_\_\_\_\_\_\_\_\_\_\_
AIRWAY ASSESSMENT:
Mouth Opening: \_\_\_\_\_ cm (normal \>3 cm)
Mallampati Class: □ I □ II □ III □ IV
Thyromental Distance: \_\_\_\_\_ cm (normal \>6 cm)
Neck Extension: □ Normal □ Limited
Dentition: □ Normal □ Loose teeth □ Crowns/bridges
Other airway concerns: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
NEUROLOGICAL EXAMINATION:
Mental Status: □ Alert □ Oriented x3 □ Confused
Speech: □ Clear □ Slurred □ Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Gait: □ Steady □ Unsteady □ Assistive device needed
ASA PHYSICAL STATUS CLASSIFICATION:
□ ASA I \- Normal healthy patient
□ ASA II \- Patient with mild systemic disease
□ ASA III \- Patient with severe systemic disease
□ ASA IV \- Patient with severe systemic disease that is constant threat to life
SEDATION APPROPRIATENESS:
□ Appropriate for office-based sedation
□ Requires medical consultation
□ Requires hospital-based care
□ Sedation contraindicated
Comments/Additional Findings:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Examiner Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_
Comprehensive informed consent documentation ensures that patients understand the risks, benefits, and alternatives to sedation while providing legal protection for the practice
- **Sedation Informed Consent Form**
INFORMED CONSENT FOR DENTAL SEDATION
Patient Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_
I understand that I will receive sedation to help me relax during my dental treatment
- My doctor has explained the type of sedation recommended for my care and has discussed the following information with me:
TYPE OF SEDATION TO BE ADMINISTERED:
□ Nitrous Oxide (Laughing Gas)
□ Oral Sedation
□ IV Conscious Sedation
□ Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
BENEFITS OF SEDATION:
• Reduced anxiety and fear during dental treatment
• Increased comfort during procedures
• Ability to complete more treatment in fewer appointments
• Reduced memory of the dental procedure
• Better cooperation during treatment
RISKS AND COMPLICATIONS:
I understand that no medical or dental procedure is 100% successful, and complications can occur
Procedure Documentation Forms
Detailed sedation administration records provide comprehensive documentation of medication administration, patient monitoring, and procedure events for regulatory compliance and quality assurance.
**Comprehensive Sedation Record**
SEDATION ADMINISTRATION AND MONITORING RECORD
Patient Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_
DOB: \_\_\_\_\_\_\_\_\_\_\_\_\_ Weight: \_\_\_\_\_\_\_ kg ASA Class: \_\_\_\_\_\_\_
Procedure: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Doctor: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Assistant: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
PRE-PROCEDURE ASSESSMENT:
Time: \_\_\_\_\_\_\_
Fasting Status: Last solid food: \_\_\_\_\_\_\_ Last liquids: \_\_\_\_\_\_\_
Baseline Vital Signs:
BP: \_\_\_/\_\_\_ HR: \_\_\_ RR: \_\_\_ SpO2: \_\_\_% Temp: \_\_\_°F
Consciousness Level: □ Alert □ Drowsy □ Other: \_\_\_\_\_\_\_\_\_\_\_
IV Access: □ Established □ Not required
Site: \_\_\_\_\_\_\_\_\_\_\_\_\_ Gauge: \_\_\_\_\_\_\_ Patency: □ Good
MEDICATIONS ADMINISTERED:
Time Medication Dose Route Given By Patient Response
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
CONTINUOUS MONITORING RECORD:
Time BP HR RR SpO2 Consciousness Procedure Events
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
CONSCIOUSNESS LEVEL SCALE:
1 \= Awake and alert
2 \= Drowsy but responsive to verbal stimuli
3 \= Drowsy but responsive to physical stimuli
4 \= Unresponsive to verbal stimuli
COMPLICATIONS/INTERVENTIONS:
Time: \_\_\_\_\_\_\_ Event: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Intervention: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Outcome: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
PROCEDURE COMPLETION:
Procedure End Time: \_\_\_\_\_\_\_
Total Sedation Time: \_\_\_\_\_\_\_
Dental Treatment Completed: □ Yes □ Partial □ No
Reason if incomplete: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
POST-PROCEDURE RECOVERY:
Time BP HR RR SpO2 Consciousness Recovery Notes
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
DISCHARGE CRITERIA MET:
□ Stable vital signs for 30 minutes
□ Adequate oxygen saturation on room air
□ Appropriate level of consciousness
□ Able to ambulate with minimal assistance
□ Responsible adult present for transportation
□ Post-procedure instructions given and understood
□ Follow-up appointment scheduled if needed
Discharge Time: \_\_\_\_\_\_\_
Discharged to care of: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Relationship: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Doctor Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_
Emergency response documentation ensures that any complications or adverse events are thoroughly documented for quality assurance, regulatory compliance, and risk management purposes.
**Emergency Response Record**
SEDATION EMERGENCY RESPONSE RECORD
Patient Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_
Time of Emergency: \_\_\_\_\_\_\_ Procedure: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Doctor: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Staff Present: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
EMERGENCY SITUATION:
□ Respiratory depression □ Cardiovascular instability
□ Allergic reaction □ Loss of consciousness
□ Airway obstruction □ Seizure
□ Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
INITIAL ASSESSMENT:
Time: \_\_\_\_\_\_\_
Consciousness: □ Alert □ Responsive to voice □ Responsive to touch □ Unresponsive
Airway: □ Clear □ Partially obstructed □ Completely obstructed
Breathing: □ Adequate □ Inadequate □ Absent
Circulation: □ Pulse present □ Pulse weak □ No pulse
Skin: □ Normal □ Pale □ Cyanotic □ Flushed
INTERVENTIONS PERFORMED:
Time Intervention Performed By Response
\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
MEDICATIONS ADMINISTERED:
Time Medication Dose Route Given By Response
\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
VITAL SIGNS DURING EMERGENCY:
Time BP HR RR SpO2 Consciousness Notes
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
EMERGENCY SERVICES:
EMS Called: □ Yes □ No Time Called: \_\_\_\_\_\_\_
EMS Arrival: \_\_\_\_\_\_\_ Transport: □ Yes □ No
Hospital: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Report Given To: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
RESOLUTION:
Emergency Resolved: □ Yes □ No Time: \_\_\_\_\_\_\_
Patient Status at Resolution:
□ Stable and alert
□ Stable but drowsy
□ Transferred to hospital
□ Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
FOLLOW-UP ACTIONS:
□ Family notified
□ Primary physician contacted
□ Incident report completed
□ Quality assurance review scheduled
□ Additional follow-up required: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
NARRATIVE DESCRIPTION:
Provide detailed description of events, timeline, and response:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Doctor Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_
Witness Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_
Key Points
- Detailed sedation administration records provide comprehensive documentation of medication administration, patient monitoring, and procedure events for regulatory compliance and quality assurance
- **Comprehensive Sedation Record**
SEDATION ADMINISTRATION AND MONITORING RECORD
Patient Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_
DOB: \_\_\_\_\_\_\_\_\_\_\_\_\_ Weight: \_\_\_\_\_\_\_ kg ASA Class: \_\_\_\_\_\_\_
Procedure: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Doctor: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Assistant: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
PRE-PROCEDURE ASSESSMENT:
Time: \_\_\_\_\_\_\_
Fasting Status: Last solid food: \_\_\_\_\_\_\_ Last liquids: \_\_\_\_\_\_\_
Baseline Vital Signs:
BP: \_\_\_/\_\_\_ HR: \_\_\_ RR: \_\_\_ SpO2: \_\_\_% Temp: \_\_\_°F
Consciousness Level: □ Alert □ Drowsy □ Other: \_\_\_\_\_\_\_\_\_\_\_
IV Access: □ Established □ Not required
Site: \_\_\_\_\_\_\_\_\_\_\_\_\_ Gauge: \_\_\_\_\_\_\_ Patency: □ Good
MEDICATIONS ADMINISTERED:
Time Medication Dose Route Given By Patient Response
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
CONTINUOUS MONITORING RECORD:
Time BP HR RR SpO2 Consciousness Procedure Events
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
CONSCIOUSNESS LEVEL SCALE:
1 \= Awake and alert
2 \= Drowsy but responsive to verbal stimuli
3 \= Drowsy but responsive to physical stimuli
4 \= Unresponsive to verbal stimuli
COMPLICATIONS/INTERVENTIONS:
Time: \_\_\_\_\_\_\_ Event: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Intervention: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Outcome: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
PROCEDURE COMPLETION:
Procedure End Time: \_\_\_\_\_\_\_
Total Sedation Time: \_\_\_\_\_\_\_
Dental Treatment Completed: □ Yes □ Partial □ No
Reason if incomplete: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
POST-PROCEDURE RECOVERY:
Time BP HR RR SpO2 Consciousness Recovery Notes
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
DISCHARGE CRITERIA MET:
□ Stable vital signs for 30 minutes
□ Adequate oxygen saturation on room air
□ Appropriate level of consciousness
□ Able to ambulate with minimal assistance
□ Responsible adult present for transportation
□ Post-procedure instructions given and understood
□ Follow-up appointment scheduled if needed
Discharge Time: \_\_\_\_\_\_\_
Discharged to care of: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Relationship: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Doctor Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_
Emergency response documentation ensures that any complications or adverse events are thoroughly documented for quality assurance, regulatory compliance, and risk management purposes
- **Emergency Response Record**
SEDATION EMERGENCY RESPONSE RECORD
Patient Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_
Time of Emergency: \_\_\_\_\_\_\_ Procedure: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Doctor: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Staff Present: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
EMERGENCY SITUATION:
□ Respiratory depression □ Cardiovascular instability
□ Allergic reaction □ Loss of consciousness
□ Airway obstruction □ Seizure
□ Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
INITIAL ASSESSMENT:
Time: \_\_\_\_\_\_\_
Consciousness: □ Alert □ Responsive to voice □ Responsive to touch □ Unresponsive
Airway: □ Clear □ Partially obstructed □ Completely obstructed
Breathing: □ Adequate □ Inadequate □ Absent
Circulation: □ Pulse present □ Pulse weak □ No pulse
Skin: □ Normal □ Pale □ Cyanotic □ Flushed
INTERVENTIONS PERFORMED:
Time Intervention Performed By Response
\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
MEDICATIONS ADMINISTERED:
Time Medication Dose Route Given By Response
\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
VITAL SIGNS DURING EMERGENCY:
Time BP HR RR SpO2 Consciousness Notes
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_ \_\_\_/\_\_ \_\_\_ \_\_\_ \_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
EMERGENCY SERVICES:
EMS Called: □ Yes □ No Time Called: \_\_\_\_\_\_\_
EMS Arrival: \_\_\_\_\_\_\_ Transport: □ Yes □ No
Hospital: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Report Given To: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
RESOLUTION:
Emergency Resolved: □ Yes □ No Time: \_\_\_\_\_\_\_
Patient Status at Resolution:
□ Stable and alert
□ Stable but drowsy
□ Transferred to hospital
□ Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
FOLLOW-UP ACTIONS:
□ Family notified
□ Primary physician contacted
□ Incident report completed
□ Quality assurance review scheduled
□ Additional follow-up required: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
NARRATIVE DESCRIPTION:
Provide detailed description of events, timeline, and response:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Doctor Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_
Witness Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_
Quality Assurance and Compliance Documentation
Systematic incident reporting is a foundational component of effective quality assurance and regulatory compliance within a dental practice. By diligently documenting and analyzing adverse events, practices can proactively identify underlying quality issues and safety concerns. This process not only supports continuous improvement efforts but also ensures adherence to established guidelines and regulations, ultimately enhancing patient safety and practice integrity.
A critical tool for this purpose is the Sedation Incident Report Form, designed to capture comprehensive details surrounding any sedation-related event. This form requires specific administrative information, including the Report Date, Incident Date, the name and position of the individual who Reported By the incident, and the Patient Name and Date of Birth (DOB). Accurate record-keeping in these fields is essential for proper tracking and analysis.
The form further categorizes incidents to facilitate detailed analysis and trend identification. Incidents are classified by severity, ranging from a "Near miss" (no patient harm) to a "Minor complication" (temporary discomfort), a "Moderate complication" (required intervention), a "Major complication" (serious harm or hospitalization), and finally, a "Sentinel event" (death or permanent harm). Additionally, the form identifies the Incident Category, covering areas such as "Medication error," "Equipment malfunction," "Monitoring failure," "Communication breakdown," "Protocol deviation," "Patient assessment error," "Emergency response," "Documentation issue," or an "Other" category for unique circumstances.
The Sedation Incident Report Form also mandates a thorough "INCIDENT DESCRIPTION," detailing specific elements. This includes an objective account of "What happened," specifying "When did it happen" (date, time, and phase of procedure), "Where did it happen" (location and operatory), and "Who was involved." Capturing these precise details ensures a complete and actionable record, enabling the practice to conduct a comprehensive review and implement targeted preventative measures.
Key Points
- Systematic incident reporting helps identify quality issues and safety concerns while supporting continuous improvement efforts and regulatory compliance
- **Sedation Incident Report Form**
SEDATION INCIDENT REPORT
Report Date: \_\_\_\_\_\_\_\_\_\_\_\_\_ Incident Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Reported By: \_\_\_\_\_\_\_\_\_\_\_\_\_ Position: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Patient Name: \_\_\_\_\_\_\_\_\_\_\_\_ DOB: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
INCIDENT CLASSIFICATION:
□ Near miss (no patient harm)
□ Minor complication (temporary discomfort)
□ Moderate complication (required intervention)
□ Major complication (serious harm or hospitalization)
□ Sentinel event (death or permanent harm)
INCIDENT CATEGORY:
□ Medication error □ Equipment malfunction
□ Monitoring failure □ Communication breakdown
□ Protocol deviation □ Patient assessment error
□ Emergency response □ Documentation issue
□ Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
INCIDENT DESCRIPTION:
What happened
- (Objective facts only)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
When did it happen
- (Date, time, phase of procedure)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Where did it happen
- (Location, operatory)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Who was involved
Regulatory Compliance Documentation
Systematic tracking of permits and licenses ensures that all regulatory requirements are maintained current while avoiding lapses that could affect service delivery.
**Regulatory Compliance Tracking Form**
SEDATION SERVICE REGULATORY COMPLIANCE TRACKING
Practice Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Last Updated: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
PRACTITIONER LICENSES AND PERMITS:
Practitioner: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Dental License Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
State: \_\_\_\_\_\_\_\_\_\_\_\_\_ Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_
Sedation Permit Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Permit Level: □ Nitrous Oxide □ Oral □ IV □ General
Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Renewal Requirements: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
FACILITY PERMITS:
Facility License: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
DEA Registration: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Controlled Substance License: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
STAFF CERTIFICATIONS:
Staff Member: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Position: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
CPR Certification: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
ACLS Certification: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Other Certifications: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
CONTINUING EDUCATION TRACKING:
Requirement: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Hours Required: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Reporting Period: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Hours Completed: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Documentation Location: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
INSPECTION SCHEDULE:
Last Inspection Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Inspector: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Results: □ Passed □ Conditional □ Failed
Next Inspection Due: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Deficiencies to Address: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
INSURANCE COVERAGE:
Professional Liability Carrier: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Policy Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Coverage Limits: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
General Liability Carrier: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Policy Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
EQUIPMENT CERTIFICATIONS:
Equipment: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Certification/Calibration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Next Due Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Service Provider: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
QUALITY ASSURANCE REQUIREMENTS:
Incident Reporting: □ Current □ Overdue
Quality Review Meetings: □ Current □ Overdue
Performance Monitoring: □ Current □ Overdue
Documentation Review: □ Current □ Overdue
RENEWAL CALENDAR:
Item Renewal Date Status
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
COMPLIANCE OFFICER: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Last Review Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Next Review Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
This comprehensive documentation system provides the foundation for safe, effective sedation practice while ensuring regulatory compliance and supporting quality assurance efforts. Regular review and updating of these forms helps ensure that they remain current with evolving standards and practice needs while providing the detailed documentation necessary for excellent patient care and legal protection.
Key Points
- Systematic tracking of permits and licenses ensures that all regulatory requirements are maintained current while avoiding lapses that could affect service delivery
- **Regulatory Compliance Tracking Form**
SEDATION SERVICE REGULATORY COMPLIANCE TRACKING
Practice Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Last Updated: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
PRACTITIONER LICENSES AND PERMITS:
Practitioner: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Dental License Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
State: \_\_\_\_\_\_\_\_\_\_\_\_\_ Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_
Sedation Permit Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Permit Level: □ Nitrous Oxide □ Oral □ IV □ General
Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Renewal Requirements: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
FACILITY PERMITS:
Facility License: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
DEA Registration: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Controlled Substance License: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
STAFF CERTIFICATIONS:
Staff Member: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Position: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
CPR Certification: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
ACLS Certification: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Other Certifications: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
CONTINUING EDUCATION TRACKING:
Requirement: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Hours Required: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Reporting Period: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Hours Completed: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Documentation Location: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
INSPECTION SCHEDULE:
Last Inspection Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Inspector: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Results: □ Passed □ Conditional □ Failed
Next Inspection Due: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Deficiencies to Address: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
INSURANCE COVERAGE:
Professional Liability Carrier: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Policy Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Coverage Limits: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
General Liability Carrier: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Policy Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Expiration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
EQUIPMENT CERTIFICATIONS:
Equipment: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Certification/Calibration Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Next Due Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Service Provider: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
QUALITY ASSURANCE REQUIREMENTS:
Incident Reporting: □ Current □ Overdue
Quality Review Meetings: □ Current □ Overdue
Performance Monitoring: □ Current □ Overdue
Documentation Review: □ Current □ Overdue
RENEWAL CALENDAR:
Item Renewal Date Status
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COMPLIANCE OFFICER: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Last Review Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Next Review Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
This comprehensive documentation system provides the foundation for safe, effective sedation practice while ensuring regulatory compliance and supporting quality assurance efforts
- Regular review and updating of these forms helps ensure that they remain current with evolving standards and practice needs while providing the detailed documentation necessary for excellent patient care and legal protection