PURPOSE: This rule provides for the requirements and guidelines dentists are required to follow in the administration of sedative drugs.

1. (1) Introduction.

   1. (A) These guidelines are provided to certificate holders in the administration of enteral or parenteral conscious sedation.
   2. (B) Implicit in the administration of sedative drugs is the dictum that they be used in a safe and effective manner.

   3. (C) The goals of conscious sedation are:

      1. 1. Sufficient control of patient behavior

to enable the practitioner to provide quality treatment;

1. 2. Prompt recovery so that the patient

leaves the office in a state of consciousness as close to normal for that patient as possible; and

1. 3. Promotion of a positive psychological

response to treatment.

1. (2) Patient Records.

   1. (A) The patient’s record shall provide a legible database that aids in treatment plan- 20 CSR 2110-4

ning and selection of the sedation technique and shall furnish the following:

1. 1. Database:

   1. A. Full name;
   2. B. Address (home and work);
   3. C. Telephone number (home and

work);

1. D. Date of birth and sex;
2. E. Height and weight;
3. F. Name of parent or guardian, if

applicable;

1. G. Name and telephone number of

person to notify in event of emergency; and

1. H. Patient’s physician’s name and

telephone number.

1. 2. Medical history:

   1. A. Chief complaint followed by histo-

ry of the present illness or a brief statement about the patient’s problem; and

1. B. Past medical history and systems

review including, but not limited to:

1. (I) Physician(s) of record;
2. (II) Hospitalizations within the last

five (5) years;

1. (III) Allergies;
2. (IV) Present medications (prescrip-

tion, nonprescription, homeopathic): dosages, intervals, and recent changes;

1. (V) Major medical illnesses, disor-

ders or abnormalities;

1. (VI) Prior anesthetic complica-

tions;

1. (VII) Breathing or respiratory diffi-

culties; (VIII) Previous hospitalizations;

1. (IX) Review of the following with

interrogative clarification of positive responses:

1. (a) Myocardial infarction;
2. (b) Hepatitis or liver disease;
3. (c) Hypertension;
4. (d) Renal disease;
5. (e) Dysrhythmias;
6. (f) Anemia;
7. (g) Angina;
8. (h) Bleeding dyscrasias;
9. (i) Heart murmur;
10. (j) Human immunodeficiency

virus (HIV);

1. (k) Congestive heart failure;
2. (l) Mitral valve prolapse;
3. (m) Rheumatic fever;
4. (n) Artificial joint; and
5. (o) Diabetes.

6. 3. Core physical examination:

   1. A. Observation of patient’s physical

stature, posture, and relative ambulatory ability;

1. B. Observation of patient’s attentive-

ness, responsiveness, and verbal ability;

1. C. Oral examination;
2. D. Potential airway problems; FINANCIAL INSTITUTIONS AND PROFESSIONAL REGISTRATION
3. E. Baseline blood pressure, heart rate

and rhythm, and respiration rate;

1. F. Temperature—only if necessary for

present problem.

1. (3) Pre-Operative Patient Evaluation and Selection.

   1. (A) Patients who are administered enteral or parenteral conscious sedation must be suitably evaluated to include, but not be limited to the following:

      1. 1. An appropriate review of the patient’s

database by the dentist to determine that data pertaining to all of the following are present:

1. A. Patient age;
2. B. Patient weight;
3. C. Individual responsible for in-

formed consent; and

1. D. Emergency contact person and

telephone number;

1. 2. An appropriate review of the medical

history with opportunity for interrogative clarification by the dentist. The record must indicate that the dentist reviewed the medical history;

1. 3. An appropriate review of the core

physical examination. The record must indicate the dentist reviewed the findings;

1. 4. An appropriate review of all medica-

tions used by the patient, both prescription and non-prescription. The record must indicate the dentist reviewed the medication inventory;

1. 5. Documented American Society of

Anesthesiologists classification; and

1. 6. Documented consultation with physi-

cians of record when indicated.

1. (4) American Society of Anesthesiologists

2. (ASA) classifications must be documented and substantiated.

   1. (A) American Society of Anesthesiologists

3. (ASA) classifications:

   1. 1. Class I—There is no organic, physio-

logic, biochemical, or psychiatric disturbance. The pathological process for which the operation is to be performed is localized and is not a systemic disturbance. The patient has no limits on his/her activity level, and in general is to be considered in good or excellent health.

1. 2. Class II—Mild-to-moderate systemic

disturbance caused either by the condition to be treated surgically or by other pathophysiological processes. The disease processes are stable or medically controlled and they are not functionally limiting. Examples: tightlycontrolled insulin or non-insulin dependent diabetes; stable asthma; symptomatic hypertension; controlled thyroid disease; smoker; obesity; or severe anxiety.

1. 3. Class III—Severe systemic distur-

bance or disease from whatever cause, even though it may not be possible to define the degree of disability with finality. Activity is significantly limited by the disease, but is not totally incapacitating. The patient may easily decompensate under stress. Examples: severe asthma; poorly controlled diabetes mellitus; angina, especially if unstable or frequent; status post (S/P) myocardial infarction of cerebral vascular accident (CVA) less than six (6) months ago.

1. 4. Class IV—Indicative of the patient

with severe systemic disorder that is a constant threat to life and not always correctable by the operative procedure. Functionally incapacitating; a totally unstable patient who is in and out of lethal states. Examples: unstable angina; congestive heart failure/ chronic obstructive pulmonary disease (CHF/COPD) requiring supplemental oxygen (O2) or wheel-chair confinement, uncontrolled systemic disease (diabetes mellitus); or symptomatic dysrhythmias.

1. 5. Class V—The moribund patient who

has little chance of survival but is submitted to operation in desperation. A hospitalized patient of the expectant category.

1. (B) Healthy or medically stable individuals (ASA Class I or II) require a review of the patient’s current medical history and medications.
2. (C) Patients who may not be medically stable or who have a significant health disability (ASA III) require a medical consultation from a physician. ASA III patients who are treated in the office setting must have evidence of the dentist’s consultation with the treating physician (written or oral) in the record. Such consultation should elicit the physician’s concurrence with decision to utilize the proposed office sedative technique.
3. (D) ASA III, IV, and V patients are not candidates for enteral sedation.
4. (E) ASA IV and V patients are not candidates for parenteral sedation outside a hospital setting.

1. (5) Informed Consent.

   1. (A) Appropriate informed consent must be obtained prior to administration of enteral or parenteral conscious sedation.

   2. (B) All of the following requirements for informed consent must be satisfied and documented prior to administration of conscious sedation:

      1. 1. The patient and/or guardian must be

advised of the specific procedure inducing enteral or parenteral conscious sedation;

1. 2. The patient and/or guardian must be

advised of the risks associated with the delivery of enteral or parenteral conscious sedation;

1. 3. The patient and/or guardian must be

advised of the options to the delivery of the enteral or parenteral conscious sedation;

1. 4. The patient or the guardian must be

advised that unforeseen circumstances do occur and the dentist and the sedation team need permission in advance to change the plan of treatment if it is deemed in their professional judgement to be in the best interest of the patient;

1. 5. The patient and/or guardian must be

afforded the opportunity to have concerns and questions addressed by the dentist; and

1. 6. The patient and/or guardian’s consent

must be documented.

1. (C) Refer to section (16) for a sample conscious sedation informed consent.

1. (6) Sedation Documentation Requirements.

   1. (A) A time oriented anesthesia record must be documented including the dosage and administration of drugs and physiologic data obtained during patient monitoring.

   2. (B) At a minimum, the anesthetic record must contain the following:

      1. 1. Names of the qualified sedation

provider and sedation team members (dentist, anesthetist, assistants);

1. 2. Date;
2. 3. Documentation of nothing by mouth;
3. 4. Vital signs recorded (blood pressure,

pulse rate, and percent of O2 saturation):

1. A. Preoperatively;
2. B. After delivery of initial medica-

tions (to include the local anesthesia); and

1. C. At a minimum every fifteen (15)

minutes throughout the procedure;

1. 5. Start and finish times for the anesthe-

sia procedure and the operative procedure;

1. 6. Agents delivered (name, dosage,

route of administration, and flow rates);

1. 7. Local anesthetics;
2. 8. Inhalation agents;
3. 9. Sedatives;
4. 10. When medications are prescribed or

dispensed, a copy of the prescription or a notation describing the medication should be in the patient’s chart with the instructions for use;

1. 11. Complications or unusual reactions

(all pertinent data, vital signs, and/or medications, etc.); and

1. 12. Discharge status.
2. (C) Monitoring data must be documented by qualified personnel capable of physical assessment of a sedated patient.

1. (7) Monitoring Procedures.

   1. (A) Conscious sedation patients shall be monitored under the direct and continuous supervision of a sedation team member.

   2. (B) For the purpose of supervising and monitoring a consciously sedated patient, members of the sedation team shall be:

      1. 1. Capable of physical assessment of a

sedated patient;

1. 2. Certified in Basic Life Support

(BLS), Cardiopulmonary Resuscitation (CPR), or Advanced Cardiopulmonary Life Support (ACLS);

1. 3. Certified in monitoring conscious

sedation from a board-approved course provider (certification of non-dentists shall be approved by their respective licensing authorities); and

1. 4. Knowledgeable about medical emer-

gency response incident to the use of enteral and parenteral conscious sedation, including the use of resuscitation equipment and emergency medications.

1. (C) Strict reliance on measuring a single physiologic parameter may be not only misleading but also potentially hazardous. As a rule, no single symptom may be diagnostic of a particular condition, but rather the total patient must be evaluated.

2. (D) Monitoring criteria include:

   1. 1. Oxygenation. Color of mucosa, skin

or blood shall be continually evaluated. Oxygen saturation must be evaluated continuously by pulse oximetry;

1. 2. Ventilation. Observation of chest

excursions and/or auscultation of breath sounds; and

1. 3. Circulation. Record initial blood

pressure and pulse and thereafter, as appropriate.

1. (E) Monitoring methods can be divided into mechanical and non-mechanical means.

   1. 1. Non-mechanical means shall include:

      1. A. Patient and blood color;
      2. B. Respiratory rate, depth and

rhythm;

1. C. Patient’s response to verbal con-

versation is an excellent gauge to depth of sedation. Is it quick, appropriate, and clear, or is it difficult to obtain, inappropriate and markedly slurred;

1. D. Body posturing; and
2. E. Skin status.

3. 2. Mechanical means shall include:

   1. A. Blood pressure and pulse rate;
   2. B. Pulse oximetry; and
   3. C. Pretracheal stethoscope, electro-

cardiogram (ECG) and temperature monitor, if appropriate.

1. (F) A consciously sedated patient must have direct and continuous supervision and monitoring until oxygenation, respiration, and circulation are stable and the patient is appropriately responsive for discharge from the facility.

1. (8) Discharge Assessment and Procedures.

   1. (A) The final responsibility for determining whether a patient is appropriately responsive and stable for discharge rests solely with the dentist. This may be done in consultation with a nurse anesthetist or an anesthesiologist.
   2. (B) Patients who have unusual reactions to enteral or parenteral conscious sedation shall be assisted and monitored until stable for discharge. Recovery must be documented.

   3. (C) The patient must be continually observed during the recovery period and discharged only when the following criteria are met:

      1. 1. Cardiovascular function is satisfacto-

ry and stable;

1. 2. Airway patency is uncompromised

and satisfactory;

1. 3. Patient is easily arousable and protec-

tive reflexes intact;

1. 4. Patient’s state of hydration is ade-

quate;

1. 5. Patient can verbalize appropriately;
2. 6. Patient can sit unaided;
3. 7. Patient can ambulate with minimal

precautionary assistance;

1. 8. For a very young child or disabled

patient, the pre-sedated level of responsiveness should be achieved;

1. 9. Appropriate post-discharge supervi-

sion confirmed; and

1. 10. Post-operative instructions reviewed

with individual responsible for post-discharge supervision.

1. (9) Personnel.

   1. (A) The minimum number of individuals available to support a sedated patient shall be three (3): the dentist and two (2) members of the sedation team, which may include a nurse anesthetist or an anesthesiologist.
   2. (B) All individuals that may be called upon to be responsible for supervising and monitoring sedated patients shall be qualified as set forth in (7)(B).

2. (10) Facilities and Equipment.

   1. (A) Access and egress to the dental facility and the operatories used for conscious sedation shall meet the requirements of the Americans with Disabilities Act (ADA) and allow access for emergency medical personnel and equipment.
   2. (B) The operatory should be large enough to permit personnel to move freely about the patient. Monitors shall be positioned for easy visualization. 20 CSR 2110-4
   3. (C) The operating table or dental chair should be positioned to permit personnel to maintain the airway, allow quick alteration of patient position, provide a firm platform for the management of cardiopulmonary resuscitation, and provide access to the patient’s oral cavity.
   4. (D) The recovery area, whether the operatory or a separate area, shall allow continuous patient visualization by personnel and have sufficient room to treat any emergency. Further, it shall be equipped with systems to allow appropriate monitoring, for providing oxygen under pressure and suction, and provide adequate lighting and electrical outlets.

   5. (E) Equipment shall include:

      1. 1. A suction system allowing tonsillar

(enteral sedation) and catheter suction (parenteral sedation);

1. 2. A positive pressure oxygen delivery

system accommodating both adult and pediatric patients (if pediatric patients are treated);

1. 3. Inhalation anesthetic systems coded to

prevent accidental administration of the wrong gas and equipped with a fail-safe mechanism;

1. 4. A portable oxygen unit with appro-

priate accessories;

1. 5. A pulse oximetry monitor;
2. 6. A defibrillator (an automatic defibril-

lator is recommended).

1. (F) An electrocardiograph is recommended equipment if the primary administrator of enteral and/or parenteral conscious sedation is competent in its use and interpretation.

2. (G) Backup systems shall include:

   1. 1. A protocol for obtaining emergency

assistance;

1. 2. Battery-powered lighting of sufficient

intensity to complete any procedure; and

1. 3. Backup suction sufficient to complete

any procedure.

1. (11) Resuscitation Equipment.

   1. (A) An emergency kit should be readily accessible and portable. It should contain drugs and equipment of appropriate sizes to resuscitate a non-breathing, unconscious patient who may also be suffering varying degrees of cardiovascular collapse to sustain life until responsibility for the patient’s care is assumed by appropriate medical personnel (e.g., emergency medical technicians (EMTs), physician, emergency room personnel).
   2. (B) Resuscitation equipment shall be immediately accessible and appropriate for the route of administration of the permit holder.

   3. (C) All conscious sedation permit holders should have immediate access to: FINANCIAL INSTITUTIONS AND PROFESSIONAL REGISTRATION

      1. 1. Airway and ventilation equipment;

         1. A. Oxygen;
         2. B. Full face masks of appropriate

sizes to accommodate all sedated patients;

1. C. Mechanism to deliver O2 with pos-

itive pressure;

1. D. Equipment for performing an

emergency cricothyroidotomy; and

1. E. Nasopharyngeal and oral airways;
2. 2. Tonsillar suction;
3. 3. Syringes and needles for intravenous

(I.V.) drug administration; and

1. 4. Unexpired medications as set forth in

section (15).

1. (D) In addition, parenteral conscious sedation permit holders should have immediate access to:

   1. 1. I.V. solutions and equipment for

establishment of an I.V. route, and appropriate fluids;

1. 2. Sterile water for injection and/or mix-

ing or dilution of drugs;

1. 3. Catheter suction; and
2. 4. Syringes and needles for I.V. drug

administration.

1. (12) Site Certificate.

   1. (A) No facility shall be the site for the administration of enteral and/or parenteral conscious sedation without being issued a site certificate pursuant to 4 CSR 110-4.020.

   2. (B) The board may require a facility requesting a site certificate for conscious sedation undergo a facility inspection. Facility inspections will be conducted by board appointed consultants from the Conscious Sedation Evaluation Committee of the Missouri Dental Board. A facility inspection will be deemed satisfactory when all criteria in subsections (12)(C) and (D) of this rule have been satisfactorily met.

      1. 1. All parenteral sedation permit appli-

cants shall receive an on-site evaluation;

1. 2. Enteral conscious sedation permit

applicants may receive an on-site evaluation; and

1. 3. The board may, at any time, inspect a

facility where conscious sedation is administered in order to verify compliance with the minimum requirements of the conscious sedation rule.

1. (C) The facility shall be properly maintained and equipped. The dentist-in-charge shall verify via notarized affidavit the following exists and is in good working order:

   1. 1. Adequate access and egress for emer-

gency medical personnel to dental facility and operatories used for sedation;

1. 2. Operatory and recovery room design

enables appropriate monitoring and emergency response;

1. 3. Emergency kit is accessible, portable,

and contains drugs and equipment of appropriate sizes to resuscitate a non-breathing, unconscious patient;

1. 4. Positive pressure oxygen and appro-

priate face masks;

1. 5. Portable oxygen;
2. 6. Tonsillar vacuum;
3. 7. Pulse oximetry;
4. 8. Pretracheal stethoscope;
5. 9. Nasopharyngeal and oral airways;
6. 10. Battery-powered lighting of suffi-

cient intensity to complete any procedure;

1. 11. Backup suction to complete any pro-

cedure; and

1. 12. Defibrillator.

2. (D) Sedation team members shall be capable of safely executing procedures associated with enteral and/or parenteral conscious sedation. The dentist-in-charge shall verify the following via notarized affidavit:

   1. 1. The primary administrator of enteral

and/or parenteral conscious sedation is a qualified sedation provider as defined in subsection (1)(S) of 4 CSR 110-4.010 who maintains current certification and licensure in their field of practice;

1. 2. Appropriate patient records are main-

tained as set forth in section (2) of this rule;

1. 3. Appropriate patient selection criteria

are employed as set forth in sections (3) and (4) of this rule. The dentist-in-charge and permitted dentists should be prepared to demonstrate knowledge of physical evaluation of patients, ASA classifications, and their application to appropriate patient selection;

1. 4. Appropriate informed consent is uti-

lized as set forth in section (5) of this rule;

1. 5. Time oriented anesthesia records are

appropriately maintained as set forth in section (6) of this rule;

1. 6. Direct and continuous monitoring of

sedated patients is accomplished by sedation team members through recovery until discharge as set forth in section (7) of this rule;

1. 7. Appropriate documentation occurs

for the management and treatment of sedated patients; and

1. 8. Appropriate criteria are in place to

determine when a patient can be safely discharged and appropriate post-operative instructions are given to responsible individuals who will supervise the sedated patient after discharge as set forth in section (8) of this rule.

1. (E) The sedation team shall be capable of responding to emergencies incident to the administration of enteral and/or parenteral conscious sedation. The sedation team should be prepared for the following emergencies and be competent in simulated responses:

   1. 1. General emergency response proto-

col;

1. 2. Laryngospasm;
2. 3. Acute airway obstruction;
3. 4. Cardiopulmonary arrest;
4. 5. Allergic reaction to drugs;
5. 6. Hypotension;
6. 7. Angina pectoris;
7. 8. Possible myocardial infarction;
8. 9. Emesis and aspiration of vomitus; and
9. 10. Convulsions.

1. (13) Board Approved Courses.

   1. (A) A course satisfying the educational requirements for an enteral conscious sedation permit shall include, but not be limited to:

      1. 1. Appropriate definitions;
      2. 2. Appropriate patient records;
      3. 3. Review of history and physical evalu-

ation;

1. 4. ASA classification;
2. 5. Indications for medical consultations;
3. 6. Appropriate patient selection;
4. 7. Properly maintained and equipped

facilities;

1. 8. Informed consent;
2. 9. Pharmacological review of common

sedatives and reversal agents;

1. 10. Time oriented anesthesia record;
2. 11. Monitoring and assessment of the

sedated patient during treatment and recovery;

1. 12. Appropriate documentation of the

management and treatment of sedated patients;

1. 13. Appropriate discharge criteria;
2. 14. Post-sedation instructions;
3. 15. Response to most common emergen-

cies incident to administration of conscious sedation; and

1. 16. An examination measuring knowl-

edge required of a dentist essential for safe and efficient conscious sedation of dental patients.

1. (B) The sedation monitoring course content shall include, but not be limited to:

   1. 1. Appropriate definitions;
   2. 2. Appropriate patient records;
   3. 3. Reviewing patient records for essen-

tial data and screening medical histories;

1. 4. ASA classification and appropriate

patient selection;

1. 5. Properly maintained and equipped

facilities;

1. 6. Informed consent;
2. 7. Time oriented anesthesia record;
3. 8. Monitoring and assessment of the

sedated patient during treatment and recovery;

1. 9. Appropriate documentation of the

management and treatment of sedated patients;

1. 10. Appropriate discharge criteria;
2. 11. Auxiliary roles in response to most

common emergencies incident to administration of conscious sedation; and

1. 12. An examination measuring knowl-

edge necessary for safe, effective monitoring of a sedated dental patient.

1. (14) References.

   1. (A) Office Anesthesia Evaluation Manual American Association of Oral and Maxillofacial Surgeons 9700 West Bryn Mawr Ave Rosemont, IL 60018
   2. (B) Guidelines for the Use of Conscious Sedation, Deep Sedation and General Anesthesia for Dentists American Dental Association 211 East Chicago Avenue Chicago, IL 60611-2678

2. (15) Emergency Drugs.

   1. (A) Minimum required emergency drugs for enteral sedation.

      1. 1. Ammonia carpules;
      2. 2. Antihistamines;
      3. 3. Benzodiazepine antagonist;
      4. 4. Bronchodilator inhaler;
      5. 5. Concentrated glucose fifty percent

(50%), (cake icing, candy, orange juice);

1. 6. Epinephrine (1:1,000 at a minimum);

and

1. 7. Nitroglycerin.

2. (B) Minimum required emergency drugs for parenteral sedation.

   1. 1. Ammonia carpules;
   2. 2. Antihistamines;
   3. 3. Atropine (or related drugs);
   4. 4. Benzodiazepine antagonist;
   5. 5. Bronchodilator inhaler;
   6. 6. Concentrated glucose fifty percent

(50%), (cake icing, candy, orange juice);

1. 7. Corticosteroid;
2. 8. Epinephrine (1:1,000 at a mini-

mum);

1. 9. Narcotic antagonist; and
2. 10. Nitroglycerin.

3. (C) Suggested but not required emergency drugs.

   1. 1. Aminophylline;
   2. 2. Hyperstat or Labetalol (or related

drugs);

1. 3. Lidocaine (one hundred (100) mg

injectables);

1. 4. Sodium bicarbonate; and
2. 5. Succinylcholine chloride.

1. (16) Sample Informed Consent for Conscious Sedation. The purpose of this document is to provide an opportunity for patients to understand and give permission for conscious sedation when provided along with dental treatment. Each item should be checked off after the patient has the opportunity for discussion and questions. ________1. I understand that the purpose of conscious sedation is to more comfortably receive necessary care. Conscious sedation is not required to provide the necessary dental care. (See #4 options.) ________2. I understand that conscious sedation is a drug-induced state of reduced awareness and decreased ability to respond. Conscious sedation is not sleep from which I can be easily awakened. My ability to respond normally returns when the effects of the sedative wear off. ________3. I understand that my conscious sedation will be achieved by the following route: ________Oral Administration: I will take a pill approximately _______ minutes before my appointment. The sedation will last approximately to hours. Patients like oral sedation because they do not need an “I.V.” line. However the level of sedation is less predictable than with “I.V.” sedation. ________Intravenous (I.V.) Administration: The anesthesia provider will inject the sedative. The length of sedation may be shorter and the level more predictable than with oral sedation. The I.V. sedation will last approximately ____ to ________ hours.

________4. I understand that the options to conscious sedation are:

1. a. No sedation: The necessary pro-

cedure is performed under local anesthetic with the patient fully aware.

1. b. Nitrous oxide sedation: Com-

monly called laughing gas, nitrous oxide provides relaxation but the patient is still generally aware of surrounding activities. Its effects can be reversed in five (5) minutes with oxygen.

1. c. General anesthetic: Commonly

called deep sedation, a patient under general anesthetic has no awareness and must have their breathing temporarily supported. General anesthesia is more appropriate for longer procedures lasting three (3) or more hours. ________5. I understand that there are risks or limitations to all procedures. For sedation these include: _______(Oral Sedation) Inadequate sedation with initial dosage may require the patient to undergo the procedure without full sedation 20 CSR 2110-4

or delay the procedure for another time. Due to unpredictable patient response, it is not recommended that oral sedatives be given in successive or additive doses. ________An atypical reaction to sedative drugs that may require emergency medical attention and/or hospitalization. _______Inability to discuss treatment options with the doctor should the circumstance require a change in treatment plan. ________6. If, during the procedure, a change in treatment is required, I authorize the dentist and the sedation team to make whatever change they deem in their professional judgment is necessary. ________7. I have had the opportunity to discuss conscious sedation and have my questions answered by sedation team members including the dentist, if I so desire. ________8. I hereby consent to conscious sedation in conjunction with my dental care. ________________ __________ _________ Patient/Guardian Date Witness

AUTHORITY: sections 332.031 and 332.361 RSMo 2000 and 332.071 RSMo Supp. 2004.* This rule originally filed as 4 CSR 110-4.030. Original rule filed Sept. 15, 2004, effective April 30, 2005. Moved to 20 CSR 2110-4.030, effective Aug. 28, 2006. *Original authority: 332.031, RSMo 1969, amended 1981, 1993, 1995; 332.071, RSMo 1969, amended 1976, 1995, 2003, 2004; and 332.361, RSMo 1969, 1981.