In today’s competitive dental landscape, continuously strengthening your skills and knowledge is vital to scaling your dental practice. Moreover, recordkeeping is the most common standard of care violation for dentists.
By Genni Burkhart
The addition of sedation dentistry to your practice adds another layer of compliance to your recordkeeping, as the DEA (United States Drug Enforcement Administration) mandates that each “registrant” who possesses controlled substances maintain complete and accurate records. Fortunately, DOCS Education provides tools to ensure your recordkeeping skills remain sharp by providing sedation education, training, and resources to keep your practice organized, efficient, and compliant.
This is the first of a two-part series that takes the mystery out of sedation dentistry recordkeeping. We’ll provide guidance on obtaining a DEA license and the requirements for sedation dentistry records. In the follow-up article, we’ll review best practices for recording and dispensing controlled substances, guidelines for storing controlled substances, and the proper handling of expired drugs.
Step One: Obtain a DEA License
To administer controlled substances as a sedation dentist, you must first register with the DEA. Essential factors in obtaining a DEA license include:
- The DEA provides a manual that specifically lays out the requirements of recordkeeping, storage, and inventory for the prescribing and dispensing of controlled substances.
- Getting an account set up can take a few weeks. Be patient and take a systemic approach to this step well before ordering and dispensing medications.
- When registering with the DEA, plan on approximately six weeks for the entire process.
- Tip: To avoid further delays, when filling out all paperwork from the start, be sure the DEA license and office address match the dental license address.
- Send copies, not originals. You won’t get them back.
After you have a DEA account, you’re now able to order sedation medications. Sedation medications in the anxiolysis protocols are schedule IV substances. Inventory records for these controlled substances must be maintained and onsite for at least two years per DEA regulations.
Accurate Recordkeeping Equals Responsible Care
Accurate documentation for sedation must be kept onsite to comply with regulations, laws, and licensing and to avoid fines. By utilizing practical ways to incorporate efficient, effective, and proper documentation of patient care, dentists honor their obligation to do no harm to the patient.
As a sedation dentist, the main components of accurate, compliant, and complete records should include:
- The pre-sedation evaluation - including dental, physical, and emotional parameters and medication administration.
- Records of drug storage, dispensing, and disposal of controlled substances.
- Administration of stocking inventory.
- End of appointment summary and disposition, oriented X 3, companion information, post-operative instructions, and proper release.
Clinical Recordkeeping: A Checklist
The following is an easy-to-follow checklist and item flow needed for sedation recordkeeping. Sedation dentistry records MUST include the following:
- Ensure your pre-sedation paperwork includes:
- Medical history.
- Completed emotional/dental exam forms.
- Need for sedation determined/dental treatment plan accepted.
- Baseline vitals were obtained.
- Social history (smoking, drinking, recreational drug history).
- Informed consent.
- The dental treatment plan was accepted, and the need for sedation was determined.
- Don’t forget the before and after instructions:
- Review with the patient before and after the sedation appointment.
- Provide the patient with instructions the day before and the day of the appointment.
- Keep all records of dispensing controlled substances to patients, including:
- Comprehensive chart notes.
- Procedures that were performed.
- Sedative meds that were dispensed.
- Dosage, times, and routes of administration of all medications and local anesthetics used.
- Disposition of patient at arrival, during sedation, and at dismissal.
- Count sheet items include:
- List procedure(s) performed.
- List each type of anesthetic given and include the time administered.
- Printout from pulse oximeter should be copied and remain part of the permanent record.
- Three vital sign readings from a pulse oximeter. Record manually during the appointment and on the standard anesthesia form.
- Complete notes after the exam.
- Required equipment for sedation includes:
- A companion chair.
- Emergency oxygen. Inspect oxygen tanks weekly, document, and keep those records onsite.
- The flow of efficient recordkeeping:
- Organization: The ordering assistant handles intake and drug reconciliation and trains dispensing team members as reconciliation assistants.
- New patient exam: Health history, medication review, social history, consent, instructions, treatment, doctor's plan, and payment by the front office.
- During the sedation visit:
- Dental assistant records and dentist reviews should be checked for accuracy. All drugs and waste, home care instructions, and paperwork should be logged and scanned into the chart.
Fail-Safe Recordkeeping
In the DOCS Home Study Course, “Compliance: Introduction to Risk Management, Recordkeeping, and the Ethics in Dental Practice,” taught by Dr. John Dovgan, DDS, a State Board consultant and expert witness, he explains the best way to avoid recordkeeping mistakes is to enact a system that prevents them in the first place.
Dr. Dovgan is a seasoned Standard of Care Investigator (SCI) with a track record that includes:
- More than 1,300 dental board cases.
- 130 lawsuits.
- Involvement in multiple state and federal class action lawsuits.
In this course, Dr. Dovgan explains the utmost importance of accurate dental recordkeeping. So much so that, based on his extensive experience, recordkeeping is where dentists get into the most trouble.
Why? Because their records don’t reflect exactly what they are doing. In fact, the number one complaint to State Dental Boards is failure to send in all records.
All records must include:
- Financial documents.
- X-Rays.
- Treatment plans.
- Health history and updates.
- Treatment notes.
- Referral documents.
- Any and all medical records sent from other treating dentists or doctors.
Enact A Red-Flag Warning System
In this informative home study course, Dr. Dovgan also explains that having ‘red flags’ for recordkeeping includes:
- The frequency of FXM (or equivalent) within 5 years, or bitewings not done in 18 months.
- Yearly periodontal charting.
- Health history update.
- If pre-medication is needed.
- A history of anaphylactic shock.
To implement this system, your staff will need to regularly review the records for each patient.
In Conclusion
As dental regulations and compliance evolve, updating skills, such as accurate recordkeeping, is essential. Simple mistakes can be costly! Stay ahead of the curve and protect your business by investing in proper training and education for accurate recordkeeping.
If you’re interested in Dr. John Dovgan’s course, you can register for it here. Upon completion of the program, you will receive a digital certificate along with 1 hour of CE credit. This online course is also beneficial for members of a state dental board, current and future dental consultants to state boards, and permit examiners.
If you're not yet subscribed to receive the Incisor newsletter, filled with cutting-edge dental news sent directly to your inbox twice a month, you can do so here.
Author: With over 14 years as a published journalist, editor, and writer, Genni Burkhart’s career has spanned across politics, healthcare, law, business finance, and news. She resides in Northern Colorado, where she works as the Editor in Chief of The Incisor at DOCS Education.
