> ## Documentation Index
> Fetch the complete documentation index at: https://docs.bizaxl.com/llms.txt
> Use this file to discover all available pages before exploring further.

# Inpatient and Sedation Management

> How to manage patients receiving dental treatment under intravenous sedation or general anaesthesia - admission, pre-operative care, procedure bays, and discharge.

Most dental treatment is performed under local anaesthesia in the dental chair without any need for the inpatient module. However, for patients receiving treatment under intravenous (IV) sedation or general anaesthesia (GA), the inpatient module provides a formal admission and discharge record that tracks the patient from arrival in the procedure bay to safe discharge with an escort.

Sedation cases at a dental clinic typically include:

* Extremely anxious patients (dental phobia) who cannot cooperate with conscious treatment
* Complex multiple extractions in one sitting (e.g., full clearance under GA)
* Wisdom tooth removal under IV sedation
* Paediatric patients requiring extensive dental rehabilitation who cannot cooperate
* Patients with severe gag reflex
* Patients with physical or intellectual disabilities requiring support

***

## Before You Start

* **Healthcare Service Units** must be set up for procedure bays and the recovery area.
* Pre-surgical blood tests must be ordered, completed, and approved before the procedure.
* Consent for the procedure and for the sedation/anaesthesia must be signed and on file.
* You need the **Healthcare Practitioner** role to create inpatient records.
* The **Nursing User** role handles pre-operative and post-operative nursing tasks.

***

## Healthcare Service Unit Setup for Sedation

Set up the following service units for a dental clinic with sedation capability:

1. Go to Healthcare workspace → Service Units card → **Healthcare Service Unit**

| Unit Name                 | Type           | Notes                                   |
| ------------------------- | -------------- | --------------------------------------- |
| Dental Chair 1 (Sedation) | Procedure Room | Chair used for sedation procedures      |
| Dental Chair 2            | Dental Chair   | Standard chair                          |
| Recovery Bay 1            | Recovery Bay   | Post-procedure monitoring bay           |
| Recovery Bay 2            | Recovery Bay   | For clinics with higher sedation volume |

***

## Step 1: Scheduling the Sedation Appointment

1. Book a Patient Appointment with type "Wisdom Tooth Removal (Sedation)" or the relevant procedure type
2. In the appointment notes, record:
   * Nil by mouth instructions (e.g., "No food or drink for 6 hours before appointment")
   * Escort requirement: "A responsible adult must accompany the patient and remain at the clinic until the patient is discharged. The patient must not drive for 24 hours."
   * Any relevant pre-operative instructions (medications to take or avoid, clothing)
3. The confirmation SMS template should include these nil-by-mouth and escort requirements (configure in Healthcare Settings)

***

## Step 2: Pre-Operative Checklist (Day of Procedure)

When the patient arrives:

1. Dental nurse verifies the pre-operative checklist using a Nursing Task:

| Check                                            | Notes                                                |
| ------------------------------------------------ | ---------------------------------------------------- |
| Patient identity confirmed                       | Name and date of birth match                         |
| Consent form signed and on file                  | Attached to the Patient Encounter                    |
| Pre-surgical blood results approved              | Confirm in the Lab Test record                       |
| Nil by mouth confirmed                           | Patient confirms no food / drink for required period |
| Escort confirmed and present in the waiting room | Record escort's name                                 |
| Allergies checked - no new allergies             | Reviewed and confirmed                               |
| Current medications reviewed                     | Particularly anticoagulants and diabetes medications |
| Blood pressure and oxygen saturation recorded    | Vital Signs record created                           |
| Patient changed into surgical gown if required   |                                                      |

***

## Step 3: Admitting the Patient

1. In the pre-operative Patient Encounter, record the **Inpatient Status** as "Admission Scheduled"
2. Go to Healthcare workspace → Inpatient card → **Inpatient Record** → New

| Field                   | What to Enter                                                                            |
| ----------------------- | ---------------------------------------------------------------------------------------- |
| Patient                 | The patient being admitted                                                               |
| Medical Department      | Oral Surgery / General Dentistry                                                         |
| Primary Practitioner    | Operating dentist or sedationist                                                         |
| Admission Ordered For   | Today's date                                                                             |
| Expected Length of Stay | Hours (e.g., for a 2-hour sedation: "0.25 days" or note "day procedure" in instructions) |
| Chief Complaint         | E.g., "Multiple impacted wisdom teeth for removal under IV sedation"                     |
| Admission Instruction   | E.g., "Nil by mouth confirmed. Escort present."                                          |

3. Assign the procedure bay:
   * Click the service unit assignment button
   * Select the available sedation chair or procedure bay
   * Save

The patient's status on their Patient record changes to **Admitted**.

***

## Step 4: Procedure Performance

The procedure is performed by the dentist and sedationist. The clinical procedure is documented in a **Clinical Procedure** record (see [Oral Surgery](/health-wellness/dental-clinic/oral-surgery) for procedure documentation details).

During the procedure, the dental nurse records:

* Sedation agent and dose administered
* Oxygen saturation and blood pressure monitoring readings during the procedure
* Any intra-procedure events

These observations can be recorded in the Inpatient Record's nursing notes or as Vital Signs records at intervals during the procedure.

***

## Step 5: Recovery

After the procedure, the patient is moved to the recovery bay:

1. Update the Inpatient Record: note transfer to recovery
2. Nursing User monitors and records:
   * Oxygen saturation (must be stable above 95% before discharge)
   * Blood pressure (must return to pre-procedure baseline)
   * Level of consciousness (patient must be oriented)
   * Pain level (score 0-10)
   * Nausea (anti-emetics given if needed)
   * Bleeding from the extraction sites

Recovery nursing tasks:

* Check oral bleeding has stopped (pressure pack in situ)
* Check patient is awake and responsive
* Allow patient to sip water when fully conscious
* Issue post-operative instructions

***

## Step 6: Discharge

When the patient meets the discharge criteria:

**Discharge criteria after IV sedation:**

* Fully conscious and oriented
* Vital signs stable for at least 30 minutes
* Able to walk without assistance
* Oral bleeding controlled
* Nausea resolved
* Escort present and briefed

1. Open the Inpatient Record
2. Complete the discharge section:

| Field                  | What to Enter                                                                                                             |
| ---------------------- | ------------------------------------------------------------------------------------------------------------------------- |
| Discharge Practitioner | Discharging dentist or sedationist                                                                                        |
| Discharge DateTime     | Actual time of departure                                                                                                  |
| Discharge Note         | Summary: procedure performed, sedation agent and dose, recovery observations, any complications, vital signs at discharge |
| Discharge Instructions | Post-operative instructions: rest today, no driving for 24 hours, no alcohol, soft diet, pain medication to take          |
| Followup Date          | Review appointment date (e.g., Day 7 for suture removal)                                                                  |

3. Submit the Inpatient Record

After submission:

* The patient's inpatient status clears from their Patient record
* The procedure bay becomes available for the next patient
* Total Patients Admitted count decreases

***

## Inpatient Medication Orders (Post-Procedure)

If medications are to be administered in the recovery bay (e.g., IV anti-emetics, additional analgesia), these are recorded as Inpatient Medication Orders:

1. Open the Inpatient Record
2. In the Drug Prescription section, add each medication to be administered
3. The nursing team sees these as Inpatient Medication Orders
4. Each dose given is recorded with the time administered

***

## Field Guide: Inpatient Record (Dental Sedation)

| Field                   | Description                                              |
| ----------------------- | -------------------------------------------------------- |
| Patient                 | The patient undergoing sedation                          |
| Medical Department      | Oral Surgery / General Dentistry                         |
| Primary Practitioner    | Operating dentist or sedationist                         |
| Status                  | Active (in procedure / recovery), Completed (discharged) |
| Admitted DateTime       | When patient was assigned to procedure bay               |
| Expected Length of Stay | Procedure + recovery time in hours                       |
| Chief Complaint         | Reason for sedation procedure                            |
| Inpatient Occupancies   | Bay assignment history                                   |
| Drug Prescription       | Medications administered during inpatient stay           |
| Discharge DateTime      | When patient left with escort                            |
| Discharge Note          | Full procedure and recovery summary                      |
| Discharge Instructions  | Post-operative instructions for patient and escort       |
| Followup Date           | Date of first post-operative review                      |

***

## Best Practices

* Never discharge a sedated patient to go home alone - confirm the escort is present and understands the aftercare instructions before discharge, and document this in the discharge note
* Blood pressure and oxygen saturation must be continuously monitored during IV sedation - use a pulse oximeter and blood pressure cuff with automatic readings and document readings at 5-minute intervals
* Create the Inpatient Record at the start of the clinic day for all planned sedation cases, not just when the patient arrives - this gives the nursing team a clear view of the day's sedation list from the morning
* Set up a dedicated sedation chair with monitoring equipment, emergency oxygen, resuscitation equipment, and antagonist drugs (Flumazenil for Midazolam reversal) - document in the service unit record that this unit has emergency equipment
* If there are any intra-operative complications (desaturation, adverse drug reaction, airway problem), document them in full detail in the discharge note regardless of the final outcome - complete documentation protects the clinic

***

## Troubleshooting

**Patient's oxygen saturation dropped during recovery**
Apply supplemental oxygen, increase monitoring frequency, delay discharge until saturations are stable. Document the event and recovery in the inpatient record. Do not discharge until the patient is fully stable.

**The escort has left the clinic before the patient is discharged**
This is a patient safety issue. The patient must not be discharged without a responsible escort. Contact the escort urgently. If the escort cannot return, arrange alternative safe transport and ensure a responsible adult will be with the patient for the remainder of the day.

**The procedure bay is showing as Occupied but the patient was discharged**
The Inpatient Record may have been saved but not submitted. Submit the record to release the bay.

***

## Related Features

* [Oral Surgery](/health-wellness/dental-clinic/oral-surgery): The clinical procedures performed during the sedation admission
* [Laboratory](/health-wellness/dental-clinic/laboratory): Pre-surgical blood tests required before sedation
* [Billing and Finance](/health-wellness/dental-clinic/billing-finance): Sedation and surgical fees are invoiced after discharge
* [Clinic Settings](/health-wellness/dental-clinic/clinic-settings): Inpatient settings and nursing checklist validation are configured in Healthcare Settings