Documentation Following Local Anesthesia Administration
- 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.
Please login or Register to submit your answer