DEEP AND GENERAL ANESTHESIA RECORD REVIEW FORM 1

TYPE A

Deep and General Anesthesia Record Review Form

6 Crescent Road, Toronto, ON Canada M4W 1T1

T: 416.961.6555 F: 416.961.5814 Toll Free: 1.800.565.4591 www.rcdso.org

Full Name of Sedation/Anesthesia Practitioner: DDS MD

Email: Phone Number:

Address of Facility:

Facility Permit Number: Name of Facility Permit Holder:

Date of Inspection: Records Reviewed By:

Does the same dentist administer sedation/GA and carry out the dental treatment? Y N

PATIENT NAME DATE *#1

#2

#3

#4

#5

Check * column if additional note required for the patient record reviewed.

# ITEM 1 2 3 4 5

MEDICAL MANAGEMENT/PRE-OPERATIVE CLINICAL CARE

1 Patient name

2 Patient age

3 Patient weight

4 Date of procedure(s)

5 Dental procedure(s) performed

6 Indication(s) for sedation

7 Medical history review

8 Allergies

9 Medications prescribed (names)

10 NPO status verified [8 hours heavy meal, 6 hours light meal, 2 hours clear fluids]

11 Pre-anesthesia accompaniment verified

PATIENT # (Place checkmark if item is documented)

DEEP AND GENERAL ANESTHESIA RECORD REVIEW FORM 2

# ITEM 1 2 3 4 5

Pre-anesthesia vitals:

12 Blood pressure (BP)

13 Heart rate (HR)

14 Oxygen saturation (O2 Sat)

15 Respiration (Resp)

16 Pre-anesthesia vitals are within normal limits Y N Y N Y N Y N Y N

17 ASA Physical Status

INTRA-OPERATIVE CLINICAL CARE

IV:

18 IV type

19 Location of venipuncture

20 Type(s) of fluid(s)

21 Volume of fluid(s) administered

Drugs administered:

22 Names of all drug(s) administered

23 Doses of all drug(s) administered

24 Route(s) of administration of all drug(s)

25 Time(s) of administration of all drug(s)

26 Were any sedative drugs prescribed to be taken out of the dental facility? Y N Y N Y N Y N Y N

27 Monitors used intra-operatively are listed

Record of vitals and ECG at 5-minute intervals:

28 Blood pressure (BP)

29 Heart rate (HR)

30 Oxygen saturation (O2 Sat)

31 Respiration

32 ECG

33 Intra-operative vitals are within normal limits Y N Y N Y N Y N Y N

34 Start and end times of sedation/GA

35 Start and end times of the dental procedure(s)

INTUBATION AND VOLATILE AGENTS

Intubation/LMA use:

36 Was the patient intubated or an LMA used? Y N Y N Y N Y N Y N

If YES, is the following true:

37 Monitoring by capnometery/capnography was used

38 Monitoring by oxygen analyzer was used

PATIENT # (Place checkmark if item is documented)

DEEP AND GENERAL ANESTHESIA RECORD REVIEW FORM 3

# ITEM 1 2 3 4 5

Use of volatile agents:

39 Was a volatile inhalational anesthetic agent used? Y N Y N Y N Y N Y N

If YES, is the following true:

40 An agent analyzer was used

41 Patient temperature was documented

POST-OPERATIVE CLINICAL CARE

Recovery period:

42 Start time of recovery

43 Appropriately recorded/appropriately monitored

44 Under continuous supervision

Record that discharge criteria were met:

45 Orientation

46 Ambulation

Record of vitals at discharge time:

47 Blood pressure (BP)

48 Heart rate (HR)

49 Oxygen saturation (O2 Sat)

50 Post-anesthesia vitals are within normal limits Y N Y N Y N Y N Y N

51 Fit for discharge time

Name(s)/signature(s) of sedation/anesthesia team members:

52 Person patient discharged to

53 Sedation/anesthesia practitioner

54 Sedation/anesthesia assistant (if applicable)

55 Recovery supervisor (if applicable)

56 Operative assistant

CASE MANAGEMENT

At the time of the chart review:

57 Comments with regards to case/notes of any complications or adverse reactions were documented

58 The information in the chart was complete and legible Y N Y N Y N Y N Y N

59 The manner in which the sedative(s) and anesthetic(s) was/were administered was appropriate Y N Y N Y N Y N Y N

60 The dose of local anesthetic was appropriate Y N Y N Y N Y N Y N

61 Management of the case was appropriate Y N Y N Y N Y N Y N

PATIENT # (Place checkmark if item is documented)

DEEP AND GENERAL ANESTHESIA RECORD REVIEW FORM 4

11/16_4414

PATIENT # ITEM

PATIENT # ITEM

PATIENT # ITEM

PATIENT # ITEM

PATIENT # ITEM

Reviewed charts have been copied and sent to the RCDSO by courier or registered mail OR scanned and sent to the RCDSO by encrypted email.

Reviewed charts have been copied and sent to the RCDSO by courier or registered mail OR scanned and sent to the RCDSO by encrypted email: Off16 1: OffBox 1 – Item: Box 1 – Patient: 12 1: Off12 2: Off12 3: Off12 4: Off12 5: Off13 1: Off13 2: Off13 3: Off13 4: Off13 5: Off14 1: Off14 2: Off14 3: Off14 4: Off14 5: Off15 1: Off15 2: Off15 3: Off15 4: Off15 5: Off17 1: Off17 2: Off17 3: Off17 4: Off17 5: Off18 1: Off18 2: Off18 3: Off18 4: Off16 2: Off16 3: Off16 4: Off16 5: Off26 1: Off26 2: Off26 3: Off26 4: Off26 5: Off18 5: Off19 1: Off19 2: Off19 3: Off19 4: Off19 5: Off20 1: Off20 2: Off20 3: Off20 4: Off20 5: Off21 1: Off21 2: Off21 3: Off21 4: Off21 5: Off22 1: Off22 2: Off22 3: Off223: Off22 5: Off23 1: Off23 2: Off23 3: Off23 4: Off23 5: Off24 1: Off24 2: Off24 3: Off24 4: Off24 5: Off25 1: Off25 2: Off25 3: Off25 4: Off25 5: Off27 2: Off27 1: Off27 3: Off27 4: Off28 1: Off28 2: Off28 3: Off28 4: Off28 5: Off29 1: Off29 2: Off29 3: Off29 4: Off29 5: Off30 1: Off30 2: Off30 3: Off30 4: Off30 5: Off31 1: Off31 2: Off31 4: Off31 5: Off32 1: Off32 3: Off32 2: Off32 4: Off32 5: Off33 1: Off33 2: Off33 3: Off33 4: Off33 5: Off34 1: Off34 2: Off34 3: Off34 4: Off34 5: Off35 1: Off35 2: Off35 3: Off35 4: Off35 5: Off36 1: Off36 2: Off36 3: Off36 4: Off36 5: Off37 1: Off37 2: Off37 3: Off37 4: Off37 5: Off38 1: Off38 2: Off38 3: Off38 4: Off38 5: Off39 1: Off39 2: Off39 3: Off39 4: Off39 5: Off40 1: Off40 2: Off40 3: Off40 4: Off40 5: Off41 1: Off41 2: Off41 3: Off41 4: Off42 1: Off42 2: Off42 3: Off42 4: Off42 5: Off43 1: Off43 2: Off43 3: Off43 4: Off43 5: Off44 1: Off44 2: Off44 3: Off44 4: Off44 5: Off45 1: Off45 2: Off45 3: Off45 4: Off45 5: Off46 1: Off46 2: Off46 3: Off46 4: Off46 5: Off47 1: Off47 2: Off47 3: Off47 4: Off47 5: Off48 1: Off48 2: Off48 3: Off48 4: Off48 5: Off49 1: Off49 2: Off49 3: Off49 4: Off49 5: Off50 1: Off50 2: Off50 3: Off50 4: Off50 5: Off51 1: Off51 3: Off51 2: Off51 4: Off51 5: Off52 1: Off52 2: Off52 3: Off52 4: Off52 5: Off53 1: Off53 2: Off53 3: Off53 4: Off53 5: Off54 1: Off54 2: Off54 3: Off54 4: Off54 5: Off55 1: Off55 2: Off55 3: Off55 4: Off55 5: Off56 1: Off56 2: Off56 3: Off56 4: Off56 5: Off57 1: Off57 2: Off57 3: Off57 4: Off57 5: Off58 1: Off58 2: Off58 3: Off58 4: Off58 5: Off59 1: Off59 2: Off59 3: Off59 4: Off59 5: Off60 1: Off60 2: Off60 3: Off60 4: Off60 5: Off61 1: Off61 2: Off61 3: Off61 4: Off61 5: OffBox 2 – Patient: Box 2 – Item: Box 3 – Patient: Box 3 – Item: Box 4 – Patient: Box 4 – Item: Box 5 – Patient: Box 5 – Item: 27 5: Off31 3: Off41 5: OffName: DDS: OffMD: OffEmail: Phone: Address: Permit Number: Name Permit Holder: Inspection: Reviewed By: GA: Off1 Name: Date 1: Check Box1: Off2 Name: Date 2: Check Box2: Off3 Name: Date 3: Check Box3: Off4 Name: Date 4: Check Box4: Off5 Name: Date 5: Check Box5: Off1 1: Off1 2: Off1 3: Off1 4: Off1 5: Off2 1: Off2 2: Off2 3: Off2 4: Off2 5: Off3 1: Off3 2: Off3 3: Off3 4: Off3 5: Off4 1: Off4 2: Off4 3: Off4 4: Off4 5: Off5 1: Off5 2: Off5 3: Off5 4: Off5 5: Off6 1: Off6 2: Off6 3: Off6 4: Off6 5: Off7 1: Off7 2: Off7 3: Off7 4: Off7 5: Off8 1: Off8 2: Off8 3: Off8 4: Off8 5: Off9 1: Off9 2: Off9 3: Off9 4: Off9 5: Off10 1: Off10 2: Off10 3: Off10 4: Off10 5: Off11 1: Off11 2: Off11 3: Off11 4: Off11 5: Off