Documentation Following Local Anesthesia Administration
Could you provide an example of appropriate documentation by a dental hygienist after the administration of local anesthesia? I want to ensure I include enough detail, particularly with the widespread use of paperless documentation templates.
Oral health professionals must address a variety of factors when administering local anesthetic agents and performing oral procedures in order to satisfy medico-legal obligations. This process begins with a thorough assessment of the patient’s medical history and vital signs.1 Critical analysis of these findings can minimize adverse outcomes. For example, following accepted blood pressure guidelines is one way to ensure patients are not exposed to undue risk during or following the administration of local anesthetic agents. A comprehensive risk assessment provides key elements to identify those who should be referred for a medical evaluation.
Open and effective communication is critical when considering risk management. The case presentation should clearly explain the benefits and risks associated with specific procedures. Implementing the principles of good communication, such as the use of lay terminology, helps patients make informed decisions when consenting to treatment. A comprehensive written consent indicates the patient and practitioner have determined the benefits outweigh the risks that may result from a specific procedure. The statutes governing informed consent vary among states; but, generally, obtaining written consent is preferred over verbal consent. Written consent and accurate documentation can minimize malpractice actions.2
Documentation in the electronic medical record (EMR) requires the same level of vigilance and detail as documentation on a paper record. An advantage of EMRs is a decrease in the incidence of illegible written notes and signatures. A signature identifies the individual who attests to the accuracy of the information in the record of service. Documentation should occur concurrently or directly following the procedure to ensure an accurate entry. The Health Information Portability and Accountability Act (HIPAA) permits patient access to review and/or amend his or her protected health record. Not many patients request to review their records, but professionals should keep this in mind when documenting the care provided.
A template can be used to ensure consistency in documentation and should ideally include the following information to ensure all aspects of care are thoroughly recorded. It may seem like a lot of information to note, but excellent communication and careful documentation will likely protect clinicians from medico-legal situations.
- Review medical history and vital signs
- Informed consent obtained
- Record the maximum recommended dose 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
- Specific vasoconstrictor administered in carpules and milligrams
- Specific procedures performed
- Record post-operative instructions (eg, how long the patient may feel numb; be careful to not bite the cheek, lip, or tongue)
- Record any reactions, including those 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
- Bassett K, DiMarco A, Naughton D. Local Anesthesia for Dental Professionals. 2nd ed. Upper Saddle River, New Jersey: Pearson Education Inc; 2015.
- Orr D, Curtis W. Obtaining written informed consent for the administration of local anesthetic in dentistry. J Am Dent Assoc. 2005;136:1568–1571.