19.16.2 Criteria for Dental Therapy Under General Anesthesia, Attachment 1
The following is medical dental policy regarding general anesthesia.
Purpose
To justify general anesthesia for dental therapy, the following documentation is required in the client's dental record.
Elements
Note those required (*) and those as appropriate (**)
1)
* Client's Demographics including Date of Birth
2)
* Relevant Dental and Medical Health History ** including Medical Evaluation Justifying Relevant Medical Condition(s)
3)
* Dental Radiographs, Intraoral/Perioral Photography, and/or Diagram of Dental Pathology
4)
* Proposed Dental Plan of Care
5)
* Signed Consent by Parent/Guardian giving permission for the proposed dental treatment and acknowledging that the reason for the use of general anesthesia for dental care has been explained.
6)
*The parent/guardian dated signature on the Criteria for Dental Therapy Under General Anesthesia form attesting that they understand and agree with the dentist's assessment of their child's behavior
7)
** Description of Relevant Behavior and Reference Scale
8)
** Other Relevant Narrative Justifying Need for General Anesthesia
9)
* Completed Criteria for Dental Therapy Under General Anesthesia form
10)
* The dentist's attestation statement and signature may be put on the bottom of the Criteria for Dental Therapy Under General Anesthesia form or included in the chart as a stand-alone form:
I attest that the client's condition and the proposed treatment plan warrant the use of general anesthesia. Appropriate documentation of medical necessity is contained in the client's record and is available in my office.
