78 OPINION

Manas Dave, Ian Corbett, Graham Walton and Kathy Wilson

DOI: 10.1308/rcsfdj.2020.78

A review of good record keeping for conscious

sedation in dentistry
by Manas Dave, Ian Corbett, Graham Walton
and Kathy Wilson

Contemporaneous and thorough record keeping

for conscious sedation in dentistry is good
clinical practice; it is necessary to ensure patient
safety and helps protect patients and clinicians
(medicolegally). Clinicians providing a sedation
service should be familiar with guidelines and
their implementation. Record keeping for
conscious sedation in dentistry is a useful audit
topic in both primary and secondary care.

Authors: Manas Dave*, Academic Clinical Fellow in Oral

and Maxillofacial Pathology, University of Manchester;
Ian Corbett, Consultant Oral Surgeon, Newcastle Dental
Hospital; Graham Walton, Consultant in Special Care
Dentistry, Newcastle Dental Hospital; and Kathy Wilson,
Associate Specialist in Sedation, Newcastle Dental Hospital

*Corresponding author:
E: manas.dave@postgrad.manchester.ac.uk

Keywords: Benzodiazepines, cannulation, dental anxiety,

dentistry, evidence-based dentistry, medical records

FACULTY DENTAL JOURNAL April 2020 • Volume 11 • Issue 2

 OPINION 79

The standard techniques for conscious sedation in den-
tistry refer to intravenous sedation (using midazolam)
and inhalation sedation (nitrous oxide and oxygen).
Both techniques allow titration of sedation according
to patient response, and can be undertaken in primary
and secondary care environments.1,2 There are several
reasons why sedation may be required in both adult
and paediatric patients. The most common reasons are
dental anxiety and phobia. Patients with severe gag re-
flexes may benefit from intravenous sedation to reduce
this response to instrumentation and in those who are
medically compromised conscious sedation may act as
a safer alternative to general anaesthesia. Procedures
that are invasive or prolonged such as dental implant
placement, surgical extractions in adults or exodontia
in children may be facilitated with conscious sedation to
reduce patient distress.
There are several behaviour management techniques
that clinicians may wish to explore prior to the provi-
sion of conscious sedation. Such techniques include
acclimatisation, distraction, ‘tell-show-do’, relaxation
techniques such as deep breathing, guided imagery
and positive reinforcement. Cognitive behaviour
therapy, hypnotherapy and acupuncture have also
been acknowledged as psychotherapeutic interven-
tions that can help with the management of dental
anxiety although availability of such modalities may
be limited. 3
Standards for conscious sedation in the provision
of dental care were published by the Intercollegiate
Advisory Committee for Sedation in Dentistry in 2015
and in 2017, the Scottish Dental Clinical Effectiveness
Programme (SDCEP) published further guidelines.1,2
These two documents include advice for facilities,
service delivery, training, record keeping and clini-
cal governance, and should be followed by all teams
providing sedation services in England, Scotland
and Wales.2
will lack validity. The consent process should inform
patients of possible alternative scenarios and agree on
a management strategy prior to the intervention.4 This
may be of particular importance in instances such as a
failed routine extraction requiring a surgical approach,
pulpal exposure during restorative intervention or a
needlestick injury to the clinician.
Consent for conscious sedation should be obtained in
writing and should not be obtained on the day of the
actual treatment unless emergency care is needed in
the patient’s best interests. An important but also easily
missed part of the consent process is reconfirmation
of consent on the day of treatment.1 It is good practice
to provide a written copy of the signed consent form
and a copy of the treatment plan to the patient so he or
she has the opportunity to revisit the discussions that
took place at a later date, reinforcing the validity of the
consent process.
For the purposes of consent, adults are classed as those
over the age of 16 years who can provide consent for
themselves whereas children are those below the age of
16 years who require someone with parental responsibil-
ity to provide consent on their behalf. Children under
the age of 16 years can be Gillick competent where they
have and can demonstrate sufficient understanding to
provide consent. However, in most cases, families (those
with parental responsibility) should be involved in the
younger patient’s care unless there is mitigation for a
specific reason.1

Record keeping is a regulatory requirement and

ensures transparency in patient care, allowing future
treatment to be carefully tailored based on the avail- Clinicians should justify the
able information and also documentation for medi-
colegal purposes. For each patient, it is essential to use of conscious sedation
record details of the ‘pre-sedation assessment, consent,
the visit for conscious sedation including monitoring, in the clinical records in a
the treatment procedure and the recovery’ (Table 1).2
Clinicians should justify the use of conscious sedation clear and concise manner
in the clinical records in a clear and concise manner.
This article will consider the importance of appropri-
ate record keeping for intravenous conscious sedation
in dentistry.

Preoperative record keeping

Clinicians are required to gain consent from patients
for their dental treatment and the sedation under-
taken.2 It is important to remember that while consent is
a continuous process, clinicians will be unable to amend
or deviate from the treatment plan once the patient
has been sedated as consent at that moment in time

FACULTY DENTAL JOURNAL April 2020 • Volume 11 • Issue 2

80 OPINION
Manas Dave, Ian Corbett, Graham Walton and Kathy Wilson

Table 1 List of Record keeping domains Key factors to consider

domains required
for record keeping in
conscious sedation2
....................................
Sedation assessment
Full medical history A number of medications can interact with benzodiazepines
Previous sedation and general Previous challenges or difficulties can be identified
anaesthesia history
Blood pressure, body mass index, heart rate and Baseline observations are required and help inform the ASA grade
oxygen saturation
Airway assessment Identification of any airway challenges during the assessment is vital
ASA status ASA grade 3 or above should be considered for management in specialised or
secondary care
Dental anxiety assessment A quantitative scoring system can be used (eg modified dental anxiety scale)
Special tests including radiographic investigations Anticipating potential perioperative challenges such as surgical extractions or
oral antral communications
Treatment plan A complete dental treatment plan should be provided to the patient,
including costs
Written consent This is essential when performing sedation and should be provided to the
patient with a copy retained in the clinical records
Verbal and written instructions to patients and Clinicians may find it useful to produce two information booklets, one for the
their escorts patient and one for the escort, to ensure there is clarity in the instructions
being delivered
Preoperative record keeping
Escort details and postoperative arrangements To ensure it is safe to proceed with sedation
Time of last intake of food and drink Anxious patients who have starved can become hypoglycaemic. Clinicians
should assess blood glucose if there are any concerns.
Any changes to medical history It is also important to check patients have taken or delayed their regular
medications as instructed
Confirmation of consent A re-check of the initial written consent in order to confirm the patient
is aware of the treatment being provided prior to any sedative agent
being administered
Perioperative record keeping
Cannulation, dose, route, time and titration For cannulation, clinicians should record the protocol (eg aseptic non-touch
technique). Dose and time records help ensure a safe titration has
been performed.
Records of patient observations Observations should be recorded before and after sedation has been
delivered. Clinicians may find it useful to record observations at set timepoints
during the treatment.
Details of personnel present in room All personnel present should be recorded and no members of staff should be
left alone with a sedated patient
Was sedation satisfactorily achieved? Patient responses to confirm sedation has been satisfactorily achieved should
be recorded
Treatment provided Details of all treatment undertaken should be noted
Any significant events? Any issues including patient compliance should be documented
Postoperative record keeping
Monitoring of patient Patients should be monitored for at least one hour following the final
increment of sedative agent
Removal of cannula
Time of discharge
Provision of written instructions to the patient
and escort

FACULTY DENTAL JOURNAL April 2020 • Volume 11 • Issue 2


Consent is not only an ethical prerequisite but also
a General Dental Council (GDC) requirement. The
GDC standards state that ‘you must obtain valid
consent before starting treatment, explaining all the
relevant options and the possible costs’ (standard
3.1).4 The Mental Capacity Act 2005 for England and
Wales provides a legal framework outlining principles
regarding an individual’s health and finance specifi-
cally around times when they do not have the mental
capacity to make decisions for themselves. A two-stage
mental capacity assessment is essential and clinicians
should be able to determine the capacity status of every
patient before completion of the consent process for
dental treatment (with or without sedation). 5 It should
be noted that Scotland and Northern Ireland have
separate mental capacity legislation.
Other items to record during the pre-sedation
assessment include a detailed medical history and
previous history of sedation as well as vital signs of
blood pressure, heart rate, oxygen saturation and
body mass index. This information will allow an
ASA (American Society of Anesthesiologists) grade
to be assigned to the patient as a guide to their
fitness for sedation and this must be documented
in the patient’s records.6 Social history can often be
a component of the assessment that is given little at-
tention. However, all clinicians should enquire about
the provision of an escort and whether the patient has
any carer or childcare responsibilities that require ad-
ditional management prior to the delivery of sedation
with benzodiazepines.
Perioperative record keeping
Perioperative record keeping should not only involve
a description of the procedure but also details on the
delivery of the sedation (such as titration as per patient
responses), the total dose of sedative delivered, patient
monitoring (such as vital signs), patient cooperation
and any supportive techniques used in conscious seda-
tion (eg if non-pharmacological behavioural manage-
ment techniques were used in conjunction with sedation
and the use of aseptic non-touch technique for cannula-
tion in intravenous sedation). Benzodiazepines have
been documented in the literature to cause memory loss
and confusion, so it is important to record the person-
nel present in the surgery and for clinicians to ensure
there is a chaperone at all times.7
Postoperative record keeping
The discharge date and time should be recorded
along with the patient’s vital signs on discharge, and
a comparison should be made with the pre-treatment
readings. In addition, assessing the patient as fit for
discharge (with an escort if intravenous sedation
is used), removal of the cannula, and provision of
written sedation discharge and postoperative dental
treatment instructions should also be noted in the
clinical records.
Given the large number of items that should be
recorded in the patient’s clinical records, clinicians
OPINION 81
Variable Record in Table 2 Parameters
clinical notes recorded in the audit
....................................
Preoperative record keeping
Was a sedation pre-assessment 117 (98.3%)
conducted?
Was body mass index recorded? 116 (96.7%)
Was an ASA grade assigned? 100 (84.0%)
Was justification for sedation recorded? 51 (42.9%)
Perioperative record keeping
Was aseptic non-touch technique 50 (42.0%)
documented?
Was level of cooperation recorded? 32 (26.9%)
Was level of sedation achieved recorded? 29 (24.4%)
Postoperative record keeping
Was time of discharge recorded? 113 (95.0%)
Was the discharge form signed by the 83 (69.7%)
clinician?
should consider using a checklist when providing seda-
tion to ensure all items are included. We recommend
the SDCEP guidelines, which provide this in a concise
format.2 All checklists need to be supplemented with a
written description but they can form a useful aide-
mémoire for clinicians.
Clinical governance
The SDCEP document highlights how important it is
to ‘monitor and constantly strive to improve the quality
of care provided to all patient groups being managed
by their dental team.’2 The process of clinical audit
is fundamental to this and the SDCEP recommends
regular audit of sedation practice including record
keeping and documentation.
The SDCEP guidelines state that clinicians are
required to ‘document the justifications for conscious
sedation and for the chosen technique in the patient’s
records.’2 Furthermore, administration of a controlled
drug should always be justified, which is why compli-
ance with this documentation would be expected to be
100%. With this in mind, an audit on record keeping
for intravenous sedation in dentistry was conducted in
a UK dental hospital in 2018.
Audit design
The aim of the audit was to assess compliance with
key components of record keeping for patients at-
tending for intravenous sedation. This was conducted
retrospectively and consecutive notes from all depart-
ments in the hospital including affiliated community
dental services that undertake intravenous sedation
were included over a six-month period. Two members
of clinical staff undertook the data collection us-
ing the same protocol. Additionally, the audit lead
randomly sampled records from both members of
staff to ensure accuracy. The results were recorded
FACULTY DENTAL JOURNAL April 2020 • Volume 11 • Issue 2
82 OPINION
Manas Dave, Ian Corbett, Graham Walton and Kathy Wilson
Auditing record keeping
for conscious sedation
in dentistry is a useful
method to ensure good
practice compliance
in an Excel® spreadsheet (Microsoft, Redmond,
WA, US).
As well as justification for sedation, other parameters
involving record keeping were reviewed including
ASA grade, and the use of aseptic non-touch tech-
nique for drawing up drugs and cannulation. All
parameters recorded are listed in Table 2 and the
standard set was 100% compliance. Identification of
key domains that are likely to be missed in the clini-
cal records can help clinicians improve their record
keeping practice.
Results
A total of 119 records were included in this audit.
The average age of patients was 37.1 years (range:
15–72 years). Almost two-thirds (61%) were female.
A range of staff groups from dental core trainees to
consultants provided intravenous sedation, and the
results for the parameters recorded are presented in
Table 2. None of the parameters met the set standard of
100% compliance.
Discussion
The results revealed a wide range of clinicians of
different grades performing intravenous sedation in
a hospital setting and showed areas in record keep-
ing that fell below the 100% target. Preoperative
assessment was generally thorough and recorded in
detail. However, it was often found that although the
individual components that determine the ASA grade
were completed, the ASA grade itself was not always
documented (recorded in 84% of cases). This has
FACULTY DENTAL JOURNAL April 2020 • Volume 11 • Issue 2
implications for ensuring patients are managed in the
most appropriate environment based on their fitness
for sedation.
While the written narrative of the clinical records
suggested the reasons sedation was prescribed, a
clear and sufficiently detailed justification was not
always provided. Justification for the prescription
of a controlled drug is a regulatory requirement,
should form the discussions around patient consent
for exposure to such medications and also has
medicolegal implications.
Recording of aseptic non-touch technique during
cannulation was inconsistent. A peripheral vascular
catheter (PVC) can act as an open wound and its
insertion increases risk of infection along with an
inadequate antisepsis technique. Following the aseptic
non-touch technique helps to reduce the risk of PVC
related infection.8
Recording of the level of sedation achieved as well
as patient cooperation during the procedure helps
provide transparency to all clinicians with access to the
notes regarding patient amenability and suitability for
future conscious sedation, and gives information on
whether any challenges with sedation were encountered
perioperatively. Additionally, recording the discharge
time in conjunction with the time of final titration of
midazolam provides clarity that the patient remained
under observation for one hour following administra-
tion of the final dose of midazolam.
The results of the audit were presented at a clinical gov-
ernance meeting and disseminated to all members of
staff with the aim of reinforcing the principles of good
record keeping within conscious sedation in dentistry
and to highlight areas that were commonly missed. Each
department was provided with individual breakdown
results to allow targeted action plans for improvements
in record keeping, and a reaudit is planned to ensure
improvements in record keeping practice and attain-
ment of the prerequisite standard.
Auditing record keeping for conscious sedation in
dentistry is a useful method to ensure good practice
compliance and for fulfilling clinical governance
requirements. Dissemination of information to the
wider dental team as a form of peer review is important
to encourage clinicians to evaluate their own record
keeping, which is a fundamental component of risk
assessment and ensuring patient safety.
Conclusions
Record keeping for conscious sedation in dentistry
involves numerous domains, some of which have the
potential to be missed more than others. Clinicians
providing a sedation service should be familiar with
guidelines and their requirements to ensure clarity
in record keeping, continuity in patient care and
safeguarding of patient safety. Record keeping for
conscious sedation in dentistry is a priority audit
 OPINION 83

topic both in primary and secondary care, and it is

hoped that clinicians can use this article to inform
their own audit practice. The example provided has
demonstrated a number of areas in record keeping
that were commonly missed and opportunities for
learning. It is essential that clinicians offering seda-
tion comply with requirements for record keeping
to reinforce good clinical practice and to fulfil their
professional obligations.

References
1. Intercollegiate Advisory Committee for Sedation in Dentistry.
Standards for Conscious Sedation in the Provision of Dental Care.
London: RCS; 2015.
2. Scottish Dental Clinical Effectiveness Programme. Conscious
Sedation in Dentistry. 3rd edn. Edinburgh: NHS Education for
Scotland; 2017.
3. Appukuttan DP. Strategies to manage patients with dental anxiety
and dental phobia: literature review. Clin Cosmet Investig Dent 2016;
8: 35–50.
4. General Dental Council. Standards for the Dental Team. London:
GDC; 2013.
5. Modgill O, Bryant C, Moosajee S. The Mental Capacity Act 2005:
considerations for obtaining consent for dental treatment. Br Dent J
2017; 222: 923–929.
6. American Society of Anesthesiologists. ASA Physical Status
Classification System. Schaumburg, IL: ASA; 2014.
7. Balasubramaniam B, Park GR. Sexual hallucinations during and
after sedation and anaesthesia. Anaesthesia 2003; 58: 549–553.
8. Zhang L, Cao S, Marsh N et al. Infection risks associated with
peripheral vascular catheters. J Infect Prev 2016; 17: 207–213.

The Royal College of Surgeons of England are

delighted to announce the launch of the new
Membership of the Faculty of Dentistry (MFDS)
examination in April 2020

The new MFDS exam has been introduced to replace the Joint Both parts of the MFDS exam will be held twice yearly (usually
Membership of the Dental Faculties (MJDF) examination. at multiple venues).

The MFDS exam is aimed at those dental professionals
who wish to demonstrate that they possess the necessary
competencies for a specialist dental career in either primary or
secondary care, following the completion of their foundation/
basic postgraduate dental training.
Candidates who have completed MJDF or MFDS Part 1 with
The Royal College of Surgeons of England will be eligible for
a 10% discount on our UK Part 2 exam which will be applied
automatically upon application.

The format of the exam will be similar to MJDF, consisting of

two parts:
• Part 1 will consist of 150 Single Best Answers
• Part 2 will consist of 14 OSCE stations (with no practical
stations included)

Part 1 of the MJDF, MFDS from the Scottish Colleges and

MFDS from the Irish College, will be equitable with the new
MFDS Part 1 examination.

For further details and examination dates, please visit: www.rcseng.ac.uk/education-and-exams/exams

FACULTY DENTAL JOURNAL April 2020 • Volume 11 • Issue 2

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