Could you provide an example of “ideal” documentation by a dental hygienist after local anesthesia is used. The level of detail is my concern, particularly in light of paperless documentation templates.
Review M.H. and vital signs
Informed consent obtained
Record the maximum recommended dose (MRD) for the anesthetic solutions you are administering (calculate prior to administration)
Specific injection(s) administered - including left or right
Specific anesthetic agent administered in carpules and milligrams (cc or mL)
Specific vasoconstrictor administered in carpules and milligrams (cc or mL)
Specific procedures performed
Record post op instructions (low long they may feel numb, be careful to not bite your cheek, lip or tongue)
Record any reactions including if they are reported after the patient has left the office. Document any conversation related to adverse reactions, complications, or side effects.
Document any follow up if necessary.