CLINICAL CHECK LIST

*Review Evaluation Page

Review Previous Notes/ Post-op Evaluation for existing clients

“Daily Care Plan”

ASSESSMENT PHASE

Initial “Medical/Dental History& Cultural Life”(* include updated form) (12pages) – Signatures:DHS, Client & RDH

  • New Medical/Dental History& Cultural Life forms every 12 months from the INITIAL date of the form; otherwise ONLY use the UPDATED forms – do NOT edit any of the medical forms once verified by an instructor

Updated Medical/ Dental History: Signatures: DHS, client & RDH

  • Vital Signs: Retake BP after 5 minutes if 1st reading is high; Need Glucose readings for Diabetics
  • “Medical Consult” Forms (if required for hypertensive readings); “ Medical Clearance: Form (if required) – Signatures:RDH or DDS
  • Ensure client has updated medication list and materials required to avoid Med. Emg. (Eg: Puffer for asthmatics, Nitroglycerine for Angina, Orange juice for Diabetics, etc…)

“Chart Audit” DHS & RDH

Sign up: RDH

STOP!!-- CAN NOT PROCEED UNTIL ‘AUTHORIZED TO PROCEED’

Do “Radiographic Needs Assessment” form: Signature: DHS Initial

 “Radiographic Prescription”: Signature: DDS for Rx

  • Client Signature required for Refusal of Radiographs / DDS signature required for retakes

“Records of Release” Form (if required) – Signatures: Client & RDH or DDS

“Chart Audit” DHS & DDS

Sign up: DDS (Can proceed)

IOE/EOE (2 pages):

Photos – Use templates (12 for a new patient and 3 for a recall/existing client)

Intra oral exam

Extra oral exam – Signature: RDH

  • Updates at the3 or 4 month continuing care interval to be noted as [ ]change or [] no changes; any changes to be noted in the ROC
  • New forms to be used at the 6+ month continuing care interval

“Chart Audit” DHS & RDH

Sign up: RDH (Can proceed)

Dentist:

Expose Rx’d Radiographs - Be observed if necessary – Ensure Quality Assurance is followed

  • Ensure “Clinical Radiology Observation” sheets are completed by RDH- if required - []1-FMS []1-BW []1-PAN: Signature: RDH
  • Mount on template in “Radiographic Interpretation” forms AND on template in “Images”

“Radiographic Interpretation” Signature: DDS

“Referral” form if required – all areas to be complete – Signature: DDS& DHS

“Caries Risk” assessment

Hard tissue charting – Signature: DDS

  • Updates at the3 or 4 month continuing care interval to be noted as [ ]change or [] no changes; any changes to be noted in the ROC
  • New forms to be used at the 6+ month continuing care interval

“Chart Audit” DHS & DDS

Sign up: DDS - Radiographic Interpretation & Hard Tissue Charting (Can proceed)

Periodontal Assessment (3 pages): (Can NOTbe evaluated without radiographs)

“Plaque Index”

Probing (Include gingival margin line):Calculate CALBleeding Index (NOTE: You can perform A PSR)

DD level – Signature: RDH

OTHER

Alginate Impressions [ ]Study Model [ ]Sportsguard [ ]Whitening Tray

“Chart Audit” DHS & RDH

Sign up: RDH (Can proceed)

ASSESSMENT CHART AUDIT COMPLETED:Signature: RDH

PLANNING PHASE

DHD’s, CCG’s (#), DHI’s (must include ALL client deficiencies, goals and DH interventions such as debridement, polish, fluoride, alginates, nutritional analysis, tobacco cessation, whitening trays, sportsguard, OSC, etc...)

Appointment sequencing

  • Include-- but not limited to the following: All interventions & OSC (be specific); Re-evalappt’s; 2-week post-op appt for whitening, etc...
  • Signature: DHS &CLIENT
  • Refusals: Signature: Client

“Chart Audit” DHS & RDH

STOP

Sign up: RDH

  • CAN NOT PROCEED UNTIL SIGNED BY THE INSTRUCTOR (see *NOTE)*NOTE:For Clinic Practice I & II (Semester 2 &3 ONLY)
  • In Clinic Practice III (Semester 4) you are allowed to proceed with debridement of half the mouth prior to being signed by an RDH faculty; HOWEVER, you must have obtained the client’s signature and DHS signature prior to beginning debridement.

Signature: RDH

  • Revisions: Signature: DHS & Client & RDH

PLANNING CHART AUDIT COMPLETED:Signature: RDH

IMPLEMENTATION PHASE

Second “Plaque Index” (At the start of last debridement appointment)

Start debridement (Re-probe if indicated and follow sequence in App’t Plan)

Sign up: RDH

  • DD1: two quads at a time; DD2/DD3: one quad at a time; DD4: sextants (and/or client specific)
  • Ensure “Clinical Competency Observation” sheets are completed by RDH- if required – [ ] 1- Ultrasonic [ ] 1- Topical Anaesthetic [ ] 1- Cetacaine [ ] 1- Subgingival Irrigation: Signature: RDH

Sealants: Evaluation Signature: RDH or DDS

  • Should be completed prior to polish and fluoride and after debridement (Ensure in treatment plan). Can be evaluated by DDS or RDH. Ensure setup tray has hand piece, round bur, and articulating paper.

Selective polishSign up: RDH (Check with RDH if can proceed)

  • Ensure “Clinical Competency Observation” sheets are completed by RDH- if required – [ ]3 polish: Signature: RDH

Fluoride Sign up: RDH

  • Ensure “Clinical Competency Observation” sheets are completed by RDH- if required – [ ] 3-Fl Tray Method [ ] 1-Fl Varnish: Signature: RDH
  • NOTE: • If a client is receiving a fluoride varnish, a conventionalfluoride treatment may not be administered on the same day.

“Transfer of Records” (if required)

Post-Op photos (3 for all clients)

Continuing Care Intervaldetermined

OTHER

Tobacco Cessation: Signature: RDH [ ] 24H Nutritional Analysis: Signature: RDH [ ] 3-Day Nutritional Analysis: Signature: RDH

Client satisfaction “Exit Survey” Form

“Chart Audit” DHS & RDH

IMPLEMENTATION CHART AUDIT COMPLETED:Signature: RDH

EVALUATION (Ongoing & Post Care)

Submitting the Post Care Evaluation: (Due within 2 weeks of completing the client)

“Post Dental Hygiene” Form 1of2 (Goals evaluated) Signature: DHS & RDH

“Clinical Learning Journal” (What I learnt from this experience): Signature: RDH

“Chart Audit” DHS & RDH **Ensure to review the ROC prior to signing up for the Post Care

4-6 WEEK RE-EVAL: (TAKES AN HOUR TO AN HOUR AND A HALF)

Med/dental history updatesSTOP! WAIT FOR AUTHORIZATION PRIOR TO PROCEEDING

Review all assessments - changes

Plaque Index

Full mouth probe (Include Gingival Margin Line) (CAL & BI)

“Post Dental Hygiene” Form 2of2 (Goals) Signature: DHS & RDH

Re-assess OSC [ ] Debride (If necessary approx..20 minutes) [ ]Review and set Continuing Care Interval

“Chart Audit” DHS & RDH

EVALUATION CHART AUDIT COMPLETED:Signature: RDH

CHAIRSIDE AUDIT COMPLETED DATE (bottom of page 3): Signature: DHS & RDH

SUBMIT POST CARE EVALUATION (Sign up in Post-Care Binder with Clinical Advisor *Within business 10 days

CONSIDERATIONS FOR ROC

Authorization to proceed (Written by RDH)

  • Medical history (Initial or Updated)/Dental/Cultural –Changes/Significant findings
  • Medical Consultation Form and/or Medical Clearance given to client re:___
  • Optional: Systemic/ Med. Emg Conditions, Vital Signs; Allergies; Chief complaint
  • Client diagnosed with _(condition)_ since _(date)_ and takes _(medication)_ for it.
  • Client has history of _(condition)_ since _(date)_ and is/not controlled.
  • Optional: Continuing Care Interval or Initial visit – last dental hygiene visit
  • Consent obtained (Written or Verbal)
  • Any Pre-procedural mouth rinses – Name, amount, time (E.g.: Preprocedural rinse Crest ProHealth 5 ml for 30 seconds)
  • Pre-op photos (#)
  • Radiographic assessment – Rx by DDS
  • Records of Release completed -Optional: Records received on –date—from Dr.__ (indicate what was received).
  • PI, IO/EO, Hard Tissue, Perio assessment completed/reviewed/verified– changes/significant findings (after verified only)
  • Caries Risk Assessment completed
  • Radiographs exposed - RX, DDS, #s (E.g.: 4BW’s, 2PA’s , PAN and/or FMS (14PA,4BW))
  • Radiographic interpretation completed/verified (Significant findings diagnosed by DDS)
  • Referral form completed and given to client
  • Treatment plan – written consent obtained (Any refusals and/or revisions noted)
  • All findings and conditions were reviewed and discussed with the client
  • **Any OSC – time (EVERY INTERVENTION NEEDS A TIME!)
  • OSC (minutes): [explained, reviewed, discussed, demonstrated, reinforced, introduced] [e.g.: brushing method, method of flossing, cavity process, periodontal disease process, tongue brushing]
  • Topical anaesthetic – 18% benzocaine, Applied to __area__
  • SubgingivalIntrasulcular topical anesthetic Cetacaine applied to _area__

Local anesthetic –MUST be written by DDS ONLY (ensure post op instructions for anesthetic is written)

  • Any Post op instructions for local
  • Debridement:Manual/ultrasonic debridement (deplaquing) of _area_ for _(duration/time)_ as per .(faculty name),_ R/RDH
  • Evidence of ongoing evaluation: E.g.: 2nd Plaque Index (PI), Tissue response, client compliant with new OSC techniques, how are they doing, new techniques required or reviewed)
  • Sealants – time, material/procedure (Pumice, 38% Phosphoric Acid, Helioseal, cured, checked occ.), teeth # & surfaces; if adjusted by who
  • Alginates – tray size, how many taken for each arch and rationale (*NOTE: If you give the client the model –note it ROC)
  • Whitening Trays Delivered: Vita Shade #, post op instructions given (summary of instructions given)
  • Tobacco and/or (24h or 3Day) Nutritional Analysis completed and verified: time
  • Optional: synopsis of the recommendations
  • Client has a high _(sugar/fast food)_ consumption, nutrition counselling required/requested/refused
  • Client is a smoker for _(duration)_ with average _(frequency)_ / day
  • Client is willing/not contemplating to quit and tobacco cessation requested/refused.
  • Client has quit smoking for _(duration)
  • Polishing – grit, flavour used, time
  • Selective/full polish with fine/medium grit (bubblegum/mint flavour) completed for _(duration)_ minutes
  • Fluoride –product, method, time, post-op instructions
  • Fluoride (2%Neutral NaFl/ 1.23%APF) (bubblegum flavour) (tray/paint-on method) delivered for 4 minutes and post-op instruction given: no eating, drinking, (smoking), or rinsing for 30 minutes
  • Varnish: Duraflur 5% NaFl varnish applied to __area__. Post op instructions: Do not brush teeth & avoid hard foods for4 hours. After 4 hours remove varnish film by brushing.
  • Any Post procedural rinses and/or subgingival irrigation *(E.g.: 0.12% chlorhexidine for 2 minutes)
  • Any Post-op instructions given (E.g.: Saline rinses, whitening procedures, sports guard, OTC meds)
  • Postop pictures
  • How client tolerated appointment
  • Exit survey completed
  • Next appointment: 4-6 re-eval, 3,6,9 month ContinuingCare Interval
  • Transfer of Records completed by client
  • *4-6 week re-eval completed: synopsis of findings indicated
  • *If client is not returning back to TCDHA must indicate in ROC

Verification and review of the record (Written by RDH)

  • *ANY contact with the client must be written in the ROC (Ex: Client no show, client late, client discontinues care)
  • Omitted Entries: Indicate the date of the omitted entry and rationale