nitrous oxide inhalation analgesia - Minnesota Board of Dentistry

SECTION 5Office/Clinic & Patient Record KeepingIn addition to the following list, the inspectors will review selected sedation patient records for procedures donewithin the previous twelve (12) months. One record MUST be submitted to the Board for review with patientnames redacted from it.___ _ Health/Medical History Form____________*Applicant must initial each of the following to indicate compliance*Anesthesia Chart showing continuous monitoring ofblood pressure, heart rate, pulse oximetry andelectocardiographic (EKG) monitoring every 5 minutesfor deep sedation/general anesthesiaDischarge Criteria FormDocumentation of Adverse Reaction & Board ofDentistry Notified with Form (found on-line)____________Emergency Treatment Documents in Progress NotesPatient Sedation Consent FormNarcotic or Scheduled Drug Inventory Log and Recordof Drugs Dispensed to Patients:____ Dispensed____ AdministeredAdditional Items to be Inspected/Evaluated: Patient’s chief complaint documentedTreatment plan documentedCore questions included on medical history form:____ 1. Are you now under a physician’s care or have you beenduring the past 5 years, including hospitalization(s) &surgery____ 2. Are you currently under a doctor’s orders or taking anymedication(s), including any birth control pills, overthe-counterdrugs, herbal supplements or home-opathicpreparations?____ 3. Do you have any allergies or are you sensitive to anydrugs or substances such penicillin, novacaine, aspirin,latex, or codeine?____ 4. Have you ever bled excessively after a cut, wound, orsurgery? Have you ever received a blood transfusion?____ 5. Are you subject to fainting, dizziness, nervousdisorders, seizures, or epilepsy?____ 6. Have you ever had any breathing difficulty, includingasthma, emphysema, chronic cough, pneumonia, TB, orany other lung disorders? Do you snore or have youbeen diagnosed with sleep apnea? Do you use tobaccoproducts?____ 7. Have you or your family members ever had anyanesthesia-related problems?____ 8. Do you have heart disease or a history of chest pain orpalpations?____ 9. Is there anything you would like to discuss alone withthe doctor?____10. Do you currently use or have a history of usingrecreational drugs?____11. Are you or might you be pregnant?____________________Radiographs – appropriately labeledWeightASA ClassificationSedation record1. ____ Agents, amounts, times administered2. ____Time-oriented anesthesia documented recordindicating supplemental oxygen-if used3. ____ Pre-treatment vital signs4. ____ Post-Treatment vital signs5. ____ Discharge vital signs6. ____ Documented continuous or periodicmonitoring of:____ blood pressure____ heart rate____ pulse oximetry____ electrocardiographic (EKG)monitoring― if required7. ____ Minimum recordings made of:____ Before beginning procedure____ Following the administrationof sedation/analgesic agents____ Completion of procedure____ During initial recovery____ Time of discharge____ Recording documented every five (5)minutes for deep sed./gen. anesthesia8. ____ Patient’s status at time of dischargeRecord of prescriptions____________Health History accomplished at every visitExamination charted with proposed procedures andprobable complicationsInformed consent____Wrongful Event Protocol:_____ Prevention protocol_____ Event protocol______ protocol includes notification to MN Bd ofDentistry6