| (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.
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