Canada RCDSO Sample Oral Moderate Sedation Record 2013 free printable template
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Sample Oral Moderate Sedation Record DATE WEIGHT PATIENTS NAME AGE MEDICAL HISTORY REVIEW CHART NO HOME PHONE ALLERGIES NPO STATUS CONFIRMED Prop BP YES NO ACCOMPANIED BY RESPONSIBLE ADULT Prop HR
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How to fill out Canada RCDSO Sample Oral Moderate Sedation Record
01
Start with the patient's identification details: Name, Date of Birth, and Patient ID.
02
Include the date of the sedation procedure at the top of the form.
03
Document the medical history by checking relevant boxes for conditions such as allergies, respiratory issues, and cardiovascular problems.
04
Record the pre-operative assessment findings, including vital signs like blood pressure, pulse, and oxygen saturation.
05
Fill in the details of the sedation administered: type of medication, dosage, and route of administration.
06
Log the start and end time of the sedation, including any interruptions or complications during the procedure.
07
Document monitoring of the patient's vital signs throughout the sedation, noting any significant changes.
08
Record any post-operative observations, including recovery status and any adverse reactions.
09
Sign and date the record upon completion, and include the signature of any supervising personnel involved.
Who needs Canada RCDSO Sample Oral Moderate Sedation Record?
01
Dentists and dental surgeons who perform procedures requiring sedation.
02
Dental clinics and offices where sedation administration is a standard practice.
03
Regulatory bodies and health authorities to ensure compliance with sedation protocols.
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What are the minimum monitoring requirements for moderate sedation?
The following must be documented, including date and time, at a minimum of every five minutes during the moderate sedation: Heart rate. Oxygen saturation. Respiratory rate. Blood pressure.
What is required monitoring during moderate sedation?
a. Vital signs, B/P, oxygen saturation, ETCO2, and cardiac rhythm are monitored every 15 minutes or less until the patient meets discharge criteria. b. Oxygen Saturation is monitored until it is maintained by patient at pre-procedure level for a minimum of 15 minutes without supplemental oxygen.
What are the criteria for discharge on the sedation record?
Criteria for discharge Cardiovascular function is satisfactory and stable. Protective reflexes are intact. Airway patency is satisfactory and stable. Patient can talk (return to presedation level).
What are the minimum monitoring parameters for sedation?
Blood pressure, heart rate, respiratory rate, oxygen saturation and level of consciousness are monitored and documented at least every 15 min or less, for a minimum of thirty minutes after the last dose of sedation medication. A written record of these parameters should be maintained in the recovery phase.
What documentation is required for moderate sedation?
The following must be documented, including date and time, at a minimum of every five minutes during the moderate sedation: Heart rate. Oxygen saturation. Respiratory rate.
What are 5 things you assess with moderate conscious sedation?
PARAMETERS: Pulse, • Respiratory rate or ventilation, Capnography • Blood pressure, • Neurological status/consciousness, • Pain distress, • Skin changes.
How do you report moderate sedation?
Moderate sedation is a time-based code with a specified unit of time of 15 minutes. However, CPT 2022 coding instructions indicate that the patient's chart must indicate a minimum of 10 minutes of intraservice time to report the initial Moderate Sedation codes 99151, 99152, 99155, and 99156.
How do you document moderate sedation?
Moderate sedation is a time-based code with a specified unit of time of 15 minutes. However, CPT 2022 coding instructions indicate that the patient's chart must indicate a minimum of 10 minutes of intraservice time to report the initial Moderate Sedation codes 99151, 99152, 99155, and 99156.
Is oral sedation moderate sedation?
Oral sedation may take some time to take effect in patients, which is why it is usually administered an hour before a procedure. It can induce minimal to moderate sedation in patients, depending on the dosage given.
What are the examples of moderate sedation?
Widely recognized mu receptor agonists include morphine sulfate, methadone hydrochloride, meperidine hydrochloride, fentanyl citrate, sufentanil citrate and alfentanil hydrochloride. Of these, fentanyl and morphine are usually chosen for moderate sedation.
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What is Canada RCDSO Sample Oral Moderate Sedation Record?
The Canada RCDSO Sample Oral Moderate Sedation Record is a standardized document used by dental professionals to record the administration of moderate sedation during oral procedures.
Who is required to file Canada RCDSO Sample Oral Moderate Sedation Record?
Dental professionals who administer moderate sedation during dental procedures are required to file the Canada RCDSO Sample Oral Moderate Sedation Record.
How to fill out Canada RCDSO Sample Oral Moderate Sedation Record?
To fill out the Canada RCDSO Sample Oral Moderate Sedation Record, practitioners must provide details such as patient information, sedation type, dosage administered, vital signs, and any relevant observations during the sedation procedure.
What is the purpose of Canada RCDSO Sample Oral Moderate Sedation Record?
The purpose of the Canada RCDSO Sample Oral Moderate Sedation Record is to ensure patient safety through proper documentation of sedation practices and to provide a clear history for future reference.
What information must be reported on Canada RCDSO Sample Oral Moderate Sedation Record?
The information that must be reported includes the patient's name and identification, the type and dosage of sedative drugs administered, monitoring of vital signs, time of administration, and any complications or notes relevant to the sedation process.
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