An Audit of Record Keeping for IV Sedation Use in Oral Surgery

520 - An Audit of Record Keeping for IV Sedation Use in Oral Surgery

GE Clancy E Carey
Presented by: Grace Clancy
Prince Charles Hospital

Introduction Record keeping for dental procedures including intravenous (IV) sedation is vital for good clinical practice. High quality notes are important in supporting detailed audits, maintaining high standards of patient care and are essential for protecting against litigation. Important guidance documents have been published to support the use of IV sedation for dental treatment including those by the Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD) and the Scottish Dental Clinical Effectiveness Programme. Templates for IV sedation procedures have been implemented in hospital settings based upon this guidance, however in one of our primary care centres freehand notes are used by surgeons for record keeping. This project aimed to audit the freehand clinical notes of our Oral Surgery/Maxillofacial team for oral surgery procedures carried out under IV sedation against the criteria laid out in Standards for Conscious Sedation in the Provision of Dental Care (IACSD). Methods Retrospective data collection for the most recent 20 IV sedation cases carried out in our primary care unit by a secondary care Maxillofacial or Oral Surgery clinician was collected and compiled. Data collection forms were generated against the essential components outlined by IV sedation standards and agreed by all Middle Grades. Patients who were treated with inhalation sedation or those receiving IV sedation for any non oral surgery procedure were excluded. Results This audit showed that all surgeons and staff members fail to include vital information in clinical records regarding IV sedation when a structured proforma is not utilised. This is the same irrespective of staff sedation experience or grade. Conclusion An automated proforma generated for use for all Oral Surgery IV sedation procedures has been implemented in practice with the aim of improving our record keeping in this area. This is currently being re-audited to establish the impact of this intervention.
Consent Statement: There are no details on individual patients reported within the abstract.

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Poster An Audit of Record Keeping for IV Sedation Use in Oral Surgery

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