Documentation

Abstract

This chapter explains the documentation required for midazolam sedation in detail. This will include the documentation for drug procurement from the pharmacy along with pre-operative, intraoperative, and post-operative documentation. Detailed annexures with samples for all the above documentation have been provided at the end of the chapter. The reader can modify them to suit her/his practice.

Appendices

Annexure 1: Pre-operative Assessment

9.1.1 Medical Questionnaire

Dear Parent,

Dental treatment plans have to be made based on the child’s medical history. So, in order to make an ideal and safe dental treatment plan for your child, please fill out the following medical history questionnaire to the best of your knowledge.

• 1. Name of the child’s physician with phone number……………………………………………………

• 2. Any recent visit to the child’s physician…………………Yes/No

• 3. Is the child on any regular medication or any recent medications?..............................Yes/No

• 4. Has the child been hospitalized in the past for any reason?...........................................Yes/No

• 5. Any abnormal bleeding associated with previous surgery or falls during play or during any other accident……………………………………………………………………………………………………………..Yes/No

• 6. Any recent X-rays, lab tests, or other investigations……………………………………………………Yes/No

• 7. Is the child allergic to any drug, food, or any other substance?......................................Yes/No

• 8. Was the child’s delivery premature?...............................................................................Yes/No

• 9. Does the child snore at night?.........................................................................................Yes/No

• 10. Is the child exposed to passive smoking?……………………………………………………………………..Yes/no

• 11. Does the child have (or had) a diagnosed medical health problem? …………………………Yes/No

• 12. If yes, can you please indicate it from the list below?

  Heart disease	Allergy to food/medicine/others	Asthma/breathing problems	Fainting spells
  Hepatitis/jaundice/liver disease	Childhood diabetes	Frequent painful/swollen joints	Kidney problems
  Tuberculosis	Thyroid problems	AIDS/HIV	Psychiatric counseling
  Anemia	Physical/developmental disability	Seizures/epilepsy	Any other problem the dentist should know

• 13. Any previous dental visits……………………………………………………………………………………………Yes/No

• 14. If yes, any serious problem with previous dental treatments

To the best of my knowledge, all the preceding answers are true and correct. In case of any change, I will inform the doctor without fail.

Parent signature and date:

Doctor’s signature and date:

9.1.2 Pre-operative Vital Signs

Pulse rate, rhythm, quality:

Respiratory rate:

Oxygen saturation:

Blood pressure:

9.1.3 Examination of the Tonsil Size

Normal/enlarged/kissing tonsils:

9.1.4 The Mallampati Score

9.1.5 History of Active Upper Respiratory Tract Infection (URTI) in the Last 4 Weeks

Coughing, active nasal discharge, wheezing/crackles, history of asthma, recent history of antibiotics for a URTI

9.1.6 BMI-for-Age Percentiles to Check for Obesity

Height:

Weight:

BMI-for-age percentiles: Normal/overweight/underweight

9.1.7 Auscultation of the Lungs and Heart

Accessory heart sounds: Yes/No

Abnormal breath sounds: Yes/No

9.1.8 ASA Score (Based on Information Above)

ASA I/ASA II/ASA III/ASA IV

Signature of the doctor with date:

Annexure 2: Informed Consent Form for Midazolam Sedation

9.1.1 Recommended Treatment

Dental treatment under midazolam sedation

Route of midazolam administration: __________________

9.1.2 Treatment Alternatives

Alternative methods of treatment are deferring the treatment temporarily with medications or completing the treatment under general anesthesia.

9.1.3 Risks and Complications

I understand that there are risks and complications associated with the administration of midazolam.

These potential risks and complications include, but are not limited to, the following:

• 1. Vomiting and aspiration if feeding instructions are not followed

• 2. Loss of consciousness

• 3. Allergic reaction

• 4. Failure to achieve any sedation

• 5. Prolonged sluggishness in motion and/or speech

• 6. Abnormal/shallow breathing

• 7. Hiccups

Any of these complications may require emergency medical attention and/or hospitalization.

I, the undersigned, acknowledge that Dr. _________________________ has explained to me that my child has to undergo dental treatment under midazolam sedation.

I have been explained that protective stabilization in the form of papoose board, mouth props, or gentle restraint of the child’s head or extremities may be necessary during the sedation appointment, to prevent sudden movements by the child.

I have been explained that nitrous oxide-oxygen may be used to further supplement the midazolam sedation and provide analgesia (pain relief).

I have been explained the need for the nature of the procedure and its possible side effects, risks, benefits, alternatives, and complications. I have understood the same and give my free and informed consent for the same to be performed.

I am also aware that I should not give anything to eat or drink to my child and see that she/he does not eat or drink on her/his own _____________ hours before the procedure as it can cause serious complications during the procedure.

I also acknowledge strongly that I have disclosed all the medical problems, if any, regarding my child to the above said doctor.

I certify and acknowledge that I have read and understood the contents of this form. It has been read and explained to me in a language understood by me.

Name/age/gender/signature of person giving the above stated consent:

Relation with the patient:

Date and time:

Name and signature of doctor taking the consent:

Doctor’s additional remarks:

Annexure 3: Pre-operative Parent Instructions

Name of the patient:

Date:

As discussed in the consultation appointment, your child requires dental treatment to be completed under midazolam sedation.

Midazolam is expected to decrease the child’s anxiety. It will calm and relax the child. It may cause moderate sedation (drowsiness) and ideally some amnesia (child will not remember what transpired during the dental procedure). The child is expected to remain interactive and awake during the dental procedure.

Kindly follow the instructions below:

• The child should be well rested before the sedation appointment. A restless child could get cranky under the effect of midazolam.

• Please bring another adult to the sedation appointment who would be able to drive while you can take care of the child in the journey back home.

• The child can bring her/his favorite toy or blanket to the appointment.

• Child should be dressed in a comfortable and loose-fitting clothing on the day of the sedation appointment.

• Please call the dental office if the child develops cold, flu, fever, or congestion 24 hours before the appointment.

• Please follow the feeding instructions strictly. Clear fluids should be avoided within 2 hours of the sedative administration, breast milk within 4 hours, light meals including non-human milk within 6 hours, and fatty meals within 8 hours. Please call the clinic in case of doubt. An empty stomach is necessary to prevent vomiting during the dental treatment.

• The child should use the washroom at home before coming to the dental office for the sedation appointment. The child can wear a diaper if toilet training is not fully established.

Signature of the doctor:

Annexure 4: Intraoperative Documentation

Name of the patient:

Date:

9.1.1 Sedation Appointment Checklist

• Functioning of the pulse oximeter.

• Functioning of the oxygen cylinder.

• Functioning of the suction apparatus.

• Functioning of the dental chair.

• Check emergency equipments list.

• Any change in the medical history.

• Any history of upper respiratory tract infections since the last visit.

• NPO (nil per oral) status.

• Compliance with washroom instructions.

• Presence of two adults.

9.1.2 Midazolam Dosage Calculation (Example Below)

Route: Oral

Child weight: 16 kg

Dosage: at 0.5 mg/kg body weight of midazolam = 8 mg of midazolam

Number of 5 mg/mL midazolam ampules required: 2 (1.6 mL)

Remarks:

9.1.3 Time-Based Record

	Baseline (9.00 AM)	9.15	9.30	9.45	10.00	10.15	10.30	10.45	11.00	11.15	11.45
Midazolam (mg)
N2O/O2 %
Local anesthetic (mg)
Sedation level
Behavior
SpO2
Respiratory rate/minute
Quality of breath sounds (normal = N)
Heart rate
Temperature
Blood pressure

9.1.4 Clinical Notes

Signature of the doctor:

Annexure 5: Discharge Criteria

Name of the patient:

Date:

• The child is responding to her/his name (if age appropriate).

• The child is sitting up unaided (if age appropriate) without dizziness.

• No signs of disorientation.

• Vital signs close to baseline.

  • SpO₂

  • Respiratory rate

  • Quality of breath sounds

  • Heart rate

  • Blood pressure

  • Temperature

• The child has stayed awake for 20 min (University of Michigan Sedation Scale, value 0) in a quiet environment.

• Post-operative instructions reviewed with the caregiver.

• Child discharged to two adults each responsible for driving the vehicle and observing the child, respectively.

Annexure 6: Post-operative Parent Instructions and Discharge Summary

Name of the patient:

Date:

Post-operative Parent Instructions

• Medications to be given to the child as prescribed.

• The soft tissues will be numb (lips, cheeks, tongue) because of the local anesthetic injection for another couple of hours. Please observe the child against lip biting or any other soft tissue trauma.

• On the way home, one adult will be in charge of driving the vehicle, and the other will be monitoring the child. Should the child wish to sleep on the way home, the airway should be kept open and chin off the chest with a head tilt.

• Once home, the child should be started initially on clear fluids. If the child accepts it well, soft foods can be started in small portions. Avoid large portions and fatty foods. The child should be well hydrated, especially for the next 24 hours.

• The child could sleep more in the next 24-hours period. During sleep, the child should be on her/his side and not in the supine position. Pillows can be placed on the back and the abdomen to stabilize the child in this position. Do not place a pillow near the child’s face.

• Parents should periodically monitor the sleeping child in general and specifically for any episodes of vomiting.

• When awake, the child should not be playing alone and should always be under close adult supervision for the next 24 hours. The child may be unsteady or dizzy, and activities like bicycle riding or climbing stairs is a strict no-no. The child could also be irritable for 24 hours.

Discharge Summary

• Date of first consultation:

• Chief complaint:

• Diagnosis:

• Treatment plan:

• Reason for treatment under midazolam sedation:

• Date of the sedation appointment:

• Dosage of midazolam administered with route:

• Any complications:

• Medications at discharge:

• Clinical notes:

Signature of the doctor with date: