034-5 Wyo. Code R. § 5-13

Current through April 27, 2019

Section 5-13 - Patient Monitoring and Necessary Documentation

(a) A dentist or permit holder shall document every administration of anxiolysis, minimal sedation, deep sedation, and/or general anesthesia.

(b) Anxiolysis and Minimal Sedation. Documentation for administration of anxiolysis (oral and nitrous oxide) and minimal sedation shall include, but not limited to, the following:

• (i) Pertinent medical history including, but not limited to:
  • (A) Previous medication(s);
  • (B) Allergies; and
  • (C) Sensitivities;

• (ii) Weight (nitrous oxide excluded);

• (iii) Vital Signs, including, but not limited to:
  • (A) Baseline heart rate; and
  • (B) Blood pressure.

• (iv) Beginning and ending oxygen saturation levels; and

• (v) Medication(s) administered and dosage(s).

(c) Moderate Sedation, Deep Sedation and/or General Anesthesia. Documentation for administration of moderate sedation, deep sedation, and/or general anesthesia shall include the required documents listed in subsection (b) and the following additional documentation:

• (i) Current and comprehensive medical history, including:
  • (A) Medical conditions; and
  • (B) Age;

• (ii) Physical examination, including:
  • (A) Airway assessment;
  • (B) Respiratory rate; and
  • (C) Temperature;

• (iii) ASA Classification;

• (iv) Procedure(s);

• (v) Informed Consent;

• (vi) Anesthesia Record, which shall include:
  • (A) Vital signs before and after anesthesia is utilized;
  • (B) Parenteral access site and method, if utilized;
  • (C) Medication(s) administered;
  • (D) Time anesthesia commenced and ended;
  • (E) Monitor blood pressure, heart rate, and oxygen saturation at least every five (5) minutes;
  • (F) EKG;
  • (G) Capnograph (end tidal carbon dioxide monitor);
  • (H) Ventilation status (spontaneous, assisted, or controlled);
  • (I) Intravenous fluids, if utilized;
  • (J) Response to anesthesia, including any complications;
  • (K) Starting time of recovery and time of discharge; and
  • (L) Condition of patient at discharge and authorization of permit holder.

034-5 Wyo. Code R. § 5-13

Adopted, Eff. 1/8/2015.

Amended, Eff. 9/26/2017.