22 Tex. Admin. Code § 110.13 - Required Preoperative Checklist for Administration of Nitrous Oxide and Levels 1, 2, 3, and 4 Sedation/Anesthesia
(a) A
dentist administering nitrous oxide or Level 1, 2, 3, or 4 sedation/anesthesia
must create, maintain, and include in the patient's dental records required by
§
108.8 of this title (relating to
Records of the Dentist) a document titled "preoperative sedation/anesthesia
checklist." The checklist must be completed prior to commencing a procedure for
which the dentist will administer nitrous oxide or Level 1, 2, 3, or 4
sedation/anesthesia. The checklist may be paper or electronic.
(b) A dentist delegating the administration
of sedation/anesthesia to another provider in accordance with Texas Occupations
Code §
258.001(4),
must maintain in the patient's dental records required by §
108.8 of this title (relating to
Records of the Dentist), a document titled "preoperative sedation/anesthesia
checklist." The checklist must be completed by the sedation/anesthesia
provider, or by the dentist delegating the procedure with information provided
by the sedation/anesthesia provider as necessary, prior to commencing a
procedure for which the dentist has delegated another provider to administer
the sedation/anesthesia. The checklist may be paper or electronic.
(c) At a minimum, the preoperative checklist
must include documentation of the following as applicable for each level of
sedation/anesthesia administered, consistent with the requirements of
§§
110.3-
110.6 of this chapter (relating to
Sedation and Anesthesia):
(1) Medical
history, including documentation of the following:
(A) review of patient medical
history;
(B) review of patient
allergies;
(C) review of patient
surgical and/or anesthesia history;
(D) review of family surgical and/or
anesthesia history; and
(E) review
of patient medications and any modifications;
(2) Confirmation that written and verbal
preoperative and post-operative instructions were delivered to the patient,
parent, legal guardian, or care-giver;
(3) Medical consults, as needed;
(4) Physical examination, including
documentation of the following:
(A) American
Society of Anesthesiologists Physical Status Classification (ASA)
classification;
(B) NPO status;
and
(C) Preoperative vitals,
including height, weight, blood pressure, pulse rate, and respiration
rate;
(5)
Anesthesia-specific physical examination including documentation of the
following as necessary for the level of sedation/anesthesia administered:
(A) Airway assessment, including Mallampati
score and/or Brodsky score as necessary for adequate patient evaluation;
and
(B) Ventilation and respiratory
rate obtained through patient observation, auscultation, or
capnography;
(6)
Confirmation of pre-procedure equipment readiness check;
(7) Confirmation of pre-procedure treatment
review (correct patient and procedure); and
(8) Special preoperative considerations as
indicated for sedation/anesthesia administered to pediatric or high risk
patients.
(d) The
preoperative checklist must include documentation of the reason for omission of
any items required by subsection (c) of this section.
(e) The information required in subsection
(c) of this section may be gathered at any time, but the dentist administering
or delegating the administration of sedation/anesthesia must verify that the
information is current and correct prior to the administration of
sedation/anesthesia.
Notes
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