FOR CHILDREN ATTENDING FOR EXODONTIA UNDER GENERAL ANAESTHETIC

Transcription

1 CLINICAL PROTOCOL FOR CHILDREN ATTENDING FOR EXODONTIA UNDER GENERAL ANAESTHETIC CLINICAL RECORDS AND PATIENT INFORMATION RATIONALE The purpose of this clinical protocol is to ensure that the clinical records of patients attending for exodontia under general anaesthesia (GA) comply with Trust standards and are accurate and complete. This ensures that each patient using the service is suitably prepared for their appointment to promote their safety and welfare (CQC 2010). BACKGROUND Referral for GA extractions comes from both:- General Dental Practitioners (GDP) Community Dentists and is a two visit process following the Guidelines for the Use of General Anaesthesia in Paediatric Dentistry (BSPD 2008). The pre-operative assessment visit is carried out in one of the Community Dental Service (CDS) clinics. It is at this visit that the diagnosis, treatment, planning and medical checks are carried out. Full pre and post operative instructions are given for the second stage of the process, i.e. the extractions under GA at Arrowe Park Hospital (APH) As the extractions at APH are usually carried out by a different dentist than the one who has done the assessment, it is vital that the GA clinical notes are accurate and complete. TARGET STAFF GROUP All dentists, dental nurses and receptionists employed by Trust Salaried Dental Service. TRAINING It is the responsibility of all dentists, dental nurses to comply with this protocol. It is the responsibility of the service manager to monitor compliance with these standards at appraisal and management supervision. 1/7

2 RELATED POLICIES Please refer to relevant Trust policies and procedures. CONSENT Valid consent must be given voluntarily by an appropriately informed person prior to any procedure or intervention. No one can give consent on behalf of another adult who is deemed to lack capacity regardless of whether the impairment is temporary or permanent. However such patients can be treated if it is deemed to be within their best interest. This must be recorded within the patient s health records with a clear rationale stated at all times. Refer to Trust Consent Policy for further information and guidance. PREPARATION OF CLINICAL RECORD Following assessment of the patient, if treatment under GA is indicated, a complete set of GA clinical notes distinguishable from the rest of the clinical notes must be prepared, itemising each procedure to be carried out under GA. In the case of patients that have been referred into the service for GA extractions these will be the only set of records. All GA clinical notes will have: patient assessment form medical history form Trust consent form 2 Practice record form (PR form) general anaesthetic extraction sheet (Printed on yellow paper) All appropriate records will also have: radiographs original referral letter from General Dental Practitioner orthodontic treatment plan GA alert card (Printed on red paper) Patient Assessment Form The patient s demographic details and the name of the referring dentist will have been completed by the receptionist prior to them coming into the surgery to see the dentist. If following clinical examination treatment under GA is indicated, the dentist will specify this treatment option on the assessment form and will then prepare a complete and distinguishable set of GA clinical notes. Medical History Form The medical history form will generally be completed by the patient or their parents/carers in the waiting room prior to them coming into the surgery to see the dentist. The dentist will check through this information to see if more detailed information is needed. If the medical history indicates that pre-operative tests and /or discussion with the 2/7

3 anaesthetist are required, prior to the patient having a general anaesthetic, the dentist will complete a GA Alert Card (red form) and place it in the clinical record. Once the medical history checks have been completed, it is the responsibility of the dentist and dental nurse to ensure that the form has: The patient s name, date of birth and NHS number The name of the patient s GP/medical consultant Is signed and dated by the parent/carer. Completion of these details will be confirmed on the GA Extraction Form (yellow form) by completion of the tick box. Consent Form Specific written consent will be obtained at the time of treatment planning using Trust Consent Form 2 which allows agreement to investigation or treatment for a child or young person. Trust staff should always comply with the Trust s Consent Policy. Seek further advice from the Trust Safeguarding Team and Line Manager if required. A copy of the consent form will be given to the parent/carer at this visit. It is the responsibility of the dentist and dental nurse to ensure that the consent form: Has the patient s name, DOB and NHS number Is signed and dated by the parent/carer Is signed and dated by the dentist Itemises the treatment to be undertaken States the teeth to be extracted match those recorded on the GA extraction form (yellow form) Has a brief explanation of the benefits and risks of treatment referencing the appropriate patient information leaflets. Completion of these details will be confirmed on the GA Extraction Form (yellow form) by completion of the tick box. If the consent form cannot be signed at this visit, e.g. parent/carer not available, then a GA Alert Card (red form) will be completed and placed in the clinical record. Practice Record Form The PR form will be completed by the receptionist at the reception desk, and will be signed and dated by the patient or their parent/carer before the patient comes into the surgery to see the dentist. The receptionist will fill in the patient s details and will complete the date of acceptance box. It is the responsibility of the dentist and dental nurse to ensure that this form has been completed and that the course of treatment number has been entered. Completion of these details will be confirmed on the GA Extraction Form (yellow form) by completion of the tick box. If the PR form is not completed at this visit then a GA Alert Card (red form) will be filled in and placed in the clinical record. 3/7

4 General Anaesthetic Extraction Sheet (yellow form) The GA extraction sheet will be completed by the dentist following the clinical examination. It is the responsibility of the dentist to ensure: The form has the patient s full name, DOB and NHS number The name of the GP/medical consultant An indication of relevant medical history The teeth to be extracted are clearly recorded on the dental chart in permanent black ink. The teeth marked for extraction match those recorded on the consent form No other dental charting is recorded on this form (e.g. cavities/fillings). The Dentist needs to tick boxes to confirm completion of medical history, consent and PR forms, and to confirm the presence of radiographs will be completed and signed off as each process is complete. If a GA Alert Card is in the clinical record then the box relating to the incomplete process must not be signed until the GA Alert Card has been removed. Radiographs It is the responsibility of the dentist carrying out the assessment, to ensure that the clinical record has radiographs for all permanent teeth that have been planned for extraction. Digital radiographs will be printed and placed in the record card. The availability of radiographs will be confirmed on the GA Extraction Sheet (yellow form) by ticking the radiograph box. If radiographs are not available at the time of the assessment then a GA Alert Card (red form) must be completed and placed in the clinical record. Referral Letter from General Dental Practitioner If the patient has been referred in to the service by a GDP, the referral letter from the practice must form part of the clinical record. Orthodontic Treatment Plan If teeth are to be extracted for orthodontic reasons, then a copy of the orthodontic treatment plan must form part of the clinical record. If the orthodontic treatment plan is not available at the time of the assessment then a GA Alert Card must be completed and placed in the clinical record. GA Alert Card (red form) The GA Alert Card will be used to highlight a problem that has arisen at the assessment appointment which means that a GA appointment cannot be booked, e.g. patient needs pre-operative tests, consent signing, radiographs are needed. The dentist will complete the GA Alert Card (red form), stating the reason for the alert, and place it in the clinical record card. Only when the outstanding issue has been dealt with can the card be removed from the clinical record and signed off on the alert card by a dentist or dental nurse. The GA Alert Card (red form) will then be filed and held in the clinic where the assessment has taken place. 4/7

5 The dentist/dental nurse will then complete and sign the GA Alert outcome box on the GA Extraction Form (yellow form) The appointment for exodontia under general anaesthetic can then be made. PATIENT INFORMATION At the assessment appointment the patient will be given information about the procedure and will be provided with pre and post operative instructions. This information will be provided in both verbal and written form by either the dentist or dental nurse as follows: Pre-operative preparation, including fasting The proposed treatment including benefits and risks The general anaesthetic including side effects and complications Appropriate escorts for the child on the day of the procedure Postoperative care and analgesia. This information is available in leaflets: Information for parents/carers bringing a child for treatment under general anaesthetic Information for patients having a tooth out Advice after tooth extraction under general anaesthetic Instructions regarding fasting time will also be written onto the patient s appointment card, and confirmation that the patient has received all instruction will be recorded in the tick box on the GA Extraction Form (yellow form). EVIDENCE THAT STANDARDS HAVE BEEN MET Confirmation that the patient has complied with all instructions, and re-checking of all documentation will be undertaken by the nurse responsible for clerking in the patient at APH. Cross checking of documentation with the GA extraction sheet (yellow form) will provide evidence that all records have been completed appropriately. WERE TO GET ADVICE FROM If guidance or advice is required by a member of staff, they are to contact their line manager for further assistance. INCIDENT REPORTING Clinical incidents or near misses must be reported and a Trust incident form must be completed. 5/7

6 SAFEGUARDIING In any situation where staff may consider the patient to be a vulnerable person, they need to follow appropriate Trust policy and discuss with their line manager and document outcomes. EQUALITY ASSESSMENT During the development of this protocol the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these named groups. REFERENCES British Society of Paediatric Dentistry (2008) Guidelines for the Use of General Anaesthesia (GA) in Paediatric Dentistry. Care Quality Commission (2010) Essential standards of quality and safety. Bibliography Department of Health (2009) Reference guide to consent for examination or treatment Department of Health (2010) Essence of Care 6/7

7 CONTROL RECORD Title Clinical Protocol for Children Attending for Exodontia under General Anaesthetic Purpose Provide Trust staff with guidance on the assessment and treatment of children attending for exodontia under general anaesthetic Author Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Francesca Daley / Caroline Hewitt Document Librarian QGS Groups consulted with :- Clinical Policies and Procedures Group Infection Control Approved N/A Date formally approved by Risk and Governance Group R&G 1 st February 2012 Method of distribution Intranet Archived Date 1 st February 2012 Location:- S Drive QGS Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 FD / CH N First version 7/7