Sedation Protocol
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Patient’s Name _________________________________________________
Date __________________________________________________________
Patient’s Dentist_________________________________________________
Procedure to be performed________________________________________
_______________________________________________________________
_______________________________________________________________
Obtain the Patient’s Folder before preparing for the Procedure
For Medico-legal Reason
Patient’s Name __________________________________
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Date ______________________________________________
Procedure to be performed_____________________________________________________________
____________________________________________________________________________________
Date of Birth___________________________________________
Sedationist Name in BLOCK Capitals
Sedation Set-up
Use a Plastic Tray for I.V. Set-up
Draw up the necessary Drugs well before the Surgery is due to start
each syringe
Cover the I.V. Set up from the sight of the patient
Pre-sedation Check
Emergency Oxygen Checked
(
)
Emergency Drug Sheet Filled out
(
)
Patient been to the Toilet
(
)
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Sedationist’s Patient Assessment
Find out from the patient’s dentist the likely state of patient’s feelings concerning
having the procedure done
Likely State of Patient’s Feelings____________________________________
_______________________________________________________________
Actual Patient’s Feelings on Arrival ________________________________
_______________________________________________________________
Time of Last Meal _______________________________________
Extent of Last Meal________________________________________________________
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Patient’s Name_______________________________________
Medical History
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Circle in Red relevant items. Add appropriate notes on lines below the Checklist.
Draw black or blue line through all items not relevant
Date___/___/___ General Health ? _____________________________________________________
Any Recent Changes in General Health
Any Weight Loss
Seen a Doctor Recently Yes /No Been to Hospital Recently Yes /No Ever been Hospitalized Yes /No
Ever had Surgery Yes /No
Medication Pills Tablets Drugs
Taking Contraceptive Pill Yes /No
Awareness of effect of Antibiotics on Effectiveness of Contraceptive Pill Yes /No
Any Serious Illnesses
Shortness of Breath
Ever had Swollen Ankles
Ever had Swollen Joints
Heart Trouble
Blood Pressure
Anaemia
Rheumatic Fever
Stomach Problems
Ever had Jaundice Kidney Problems Thyroid Problems Liver Disease Hepatitis
Chest Pain on Exertion
Persistent Cough
Diabetes
Bleeding Problems
Epilepsy
Tuberculosis Bronchitis
Chest Problems
Asthma
Radiation Treatment to Head or Neck
Treatment of Growths or Tumours Nervous Problems
Headaches
Migraine
Pregnancy
Sinus Problems
Smoking__________________________________________________
Alcohol Problems
Aspirin Allergy
Penicillin Allergy
Other Allergies_________________________________________
Chlorhexidine Allergy
Iodine Allergy
Occupation __________________________________
Drugs Currently taken______________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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Sedationist’s Consent for Sedation
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Procedure to be performed________________________________________________________
____________________________________________________
______________________________________________________________________________________________
Concerning the treatment to be performed
1 I have been informed and I understand the purpose and the nature of the surgical
procedure to be performed.
2 My dentist has carefully examined my mouth and alternatives to this treatment have
been explained.
3 To my knowledge I have given an accurate report of my physical and mental
history. I have also reported any prior allergic or unusual reactions to drugs, foods,
insect bites, anaesthetics, pollen, dust, blood or body diseases, gum or skin
reactions, abnormal bleeding or any other conditions related to my health.
Concerning the treatment to be performed
1 I agree to the type of sedation, which has been explained to me, depending on the
decision of the sedationist.
2 The alternatives to sedation such as local anaesthetic alone or a general anaesthetic
have been explained to me and I have chosen sedation.
Pre-sedation Instructions
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I understand that I should have a light non-fatty meal 4 hours before sedation and
must not drink anything from 2 hours before.
2 I give my full consent to my dentist to arrange for a fully qualified dental
sedationist to administer my sedation
3 The effects of sedation have been fully explained to me.
4 I understand that I will be sufficiently awake to converse with the sedationist
throughout the procedure
5 I have been informed that after sedation my judgement will be impaired for some
hours and I may not remember the procedure.
6 I understand that I must not drive a car, use machinery, cook or make any important
decisions for at least 24 hours.
7 I understand that I must not be left in charge of children.
8 I have been told that I may have a feeling of wellbeing and being able to cope with
normal situations when in fact I may not be fit to do so.
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9 My dentist has explained to me that additional procedures may become necessary
during the sedation. I consent that the dentist who is performing the procedure
should proceed with these treatments should they become necessary.
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10 I have been given instructions to follow both before and after the operation.
11 I agree to the photographing and videoing of the treatment to be performed on me.
12 I agree to go directly home after the procedure, accompanied by a responsible
adult who will remain with me over night to look after me. I agree to rest quietly
there for at least 12 hours.
Please wear Loose Clothing for the Appointment
I have been given the opportunity to ask questions about sedation.
I am satisfied with all the information and explanations and alternatives that have
been given to me
I have read and understood this consent form and have been given a copy to take home
Initial _________
Patients Name_________________________________________________________
Patient's Signature .................................................................Date................................
Sedationist’s Name (In Block Capitals)………..................................................................
Sedationist’s Signature .................................................................Date................................
Stuart Orton-Jones 33 High Street, Harpole, Northampton, NN7 4DH, UK. Telephone:
- 01604 832399 Fax: - 01604 832867 Mobile: - 07885 349300
email stuart@orton-jones.telinco.co.uk
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Sedation Record
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Patients Name______________________________________________________Date_________/____________/_________
Preoperative Patient Preparation
Ibuprofen_____________________________Corsodyl Rinsing and Toothbrushing (
)
Antibiotics Administered____________________________________________________
Other Information_________________________________________________________
Initial Starting Information
Blood Pressure
Preoperatively________/_________
Postoperatively________/_________
Start Time ___________________________Start Oxygen Level _____________________
Starting Pulse _________________________
Venipunctures Site
Right Anticubital Fossa (
Left Anticubital Fossa (
)
)
Right Hand (
Left Hand (
)
Right Foot (
) Left Foot (
)
)
Other Information________________________________________________________________
Patients Name________________________________Date_________/____________/__________
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Induction Dose
Robinul (200 microgm)____________ug
Dexamethazone( 8mgm 2ml) ____________mgm
Total Drugs given
Robinul (200 microgm)________ug
Dexamethazone( 8mgm 2ml) ___________mgm Midazolam mgm ____________
Anexate _________________microgm Local Anaesthetic____________________________________________
Venepuncture performed by
in BLOCK Capitals ___________________________________Signature_____________
Time
Blood Pressure
Oxygen
Level
Pulse Midazolam
Local
Anaesthetic
cc
Other
/ Total
___/______//_______/________//_______//_______//___________//______/______//______________
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Ask Patient Prepper to proceed Prepping
Time
Blood Pressure
Oxygen
Level
Pulse
Midazolam
Local
Anaesthetic
Other
___/______//_______/________//_______//_______//___________//_____________//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//____________
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___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
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___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
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Patients Name________________________________Date_________/____________/_________
Oxygen
Local
Time
Blood Pressure
Level
Pulse Midazolam
Anaesthetic
Other
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
___/______//_______/________//_______//_______//___________//______/______//______________
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Record of Clinical Treatment
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Patient’s Name___________________________________________________________Date__________________________
Operator’s Name in BLOCK Capitals ______________________________________________________________________
Participant’s Dentist Name in BLOCK Capitals ______________________________________________________________
Operator’s Write-up of Procedure
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Operator’s Signature______________________________________________________________________________
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Postoperative Care to help healing.
postop.wpd
For the next Few Days after Surgery.
1. Alcohol. Avoid alcohol for 2 weeks as this can affect the healing of the tissues.
2. Smoking. Avoid smoking for 3 days before treatment and 2 weeks after.
Smoking slows down the healing process.
3. Avoid Very Hot Food and Drinks and spicy and acidic foods.
4 Avoid Hard Crusty Foods.
5. A surgical dressing may be placed around the incision after surgery. This should
remain in place for one to two weeks.
6. Avoid Vigorously Brushing this area Clean gently.
7. Do not use play with the area with your tongue,
8. If you have had a sinus graft procedure, or upper posterior implants placed,
a) Please avoid blowing your nose for approximately 2 weeks after surgery.
This will help prevent infection.
b) Please try and sneeze through your mouth and not through your nose.
c) Please avoid swimming for 2 weeks after surgery
First and Second Week.
1. Rinse with Chlorhexidine ( Corsodyl ) twice a day.
2. Take antibiotics and pain relieving pills as prescribed.
Finish the course of antibiotics.
If you have a reaction to the medication, please telephone.
4. Avoid brushing the area.
5. Maintain a soft, high protein diet.
6. Avoid excessive physical exertion (i.e. sports, heavy lifting etc.).
Third Week
Lightly brush the area.
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Fourth Week. Resume normal cleaning.
It is very important that you maintain your oral hygiene and home care at a high standard
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and that you attend for regular check-up appointments.
I have been given the opportunity to ask questions about my treatment and
understand the post-operative instructions.
If anything concerns you at any time contact your dentist immediately.
If you are not able to contact your Dentist,
contact Stuart Orton-Jones.
I have read this, have understood it and have a copy to take home.
Patient's Name in BLOCK Capitals
___________________________________________Signature_____________
Patient's Escort Name in BLOCK Capitals
___________________________________________Signature________________
To be signed by the Dentist who gives the Post-operative instructions to the Escort
Dentist giving Instructions Name in BLOCK Capitals
________________________________________Signature______________________
Stuart Orton-Jones 33 High Street Harpole Northampton England. Telephone:01604 832399 Fax:- 01604 832867 (Mobile) 07885 349300
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Fitness to leave Assessment
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Tick Brackets if the Patient passes Each Test
Patient’s Name _______________________________Date_______________
1. Vital Signs Stable
Blood Pressure ______/______
Pulse
___________/minute
Patient alertness
Ask the Patient
Today’s date
(
)
Date of birth,
(
)
Their Home Address
(
)
2. Check protecting reflexes
Swallowing , give patient a sip of water
Breathing Deeply and Cough
(
(
)
Walking in a straight line
(
)
Let patient turn around
(
)
Lift one leg up for a few seconds (
)
)
3. Balance Test
4. No Post-operative Nausea and Vomiting (
5. Pain Controlled
(
)
6. Bleeding Control Verified
(
)
)
7. Canulla Removed
8. Denture/Temporary Bridge adjusted and fitted (
Fit to discharge
)
Yes/No
Date ________________________
Time of Discharge_______________am / pm_
Discharged by
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Print Name______________________________Signiture______________________
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