Policies & Procedures Manual (Template) January 2015

Policies & Procedures Manual

(Template)

January 2015

2400 Computer Drive

Westborough, MA 01581

T: 508.329.2280

W:

P a g e |2

D ISCLAIMER

Great care was taken to make these policies and procedures comprehensive and compliant with requirements and

recommendations from organizations such as OSHA, CDC, and the ADA. References to source information are

footnoted where appropriate.

Laws and recommendations from these organizations are numerous and subject to change. SNS cannot

guarantee this document complies with any federal or state laws. SNS also cannot accept responsibility if any

information in this document is in conflict with these laws. SNS does not undertake to provide updates to this

document as any relevant laws or other requirements change over time. Before the policies and procedures in this

document are implemented at any dental clinic, we strongly encourage the organization to review federal and

local laws and have policies and procedures approved by health care professionals where appropriate.

Safety Net Solutions (SNS) created this template to assist safety net dental clinics in establishing their own policies

and procedures manual. We encourage clinics to carefully review the contents of this document and modify them

for their own circumstances. Each clinic may also have its own unique policies or procedures that should be

included in its manual. This template was not designed to directly substitute for a clinic¡¯s own manual; it requires

that clinics add additional information throughout the document, referenced between brackets in the color blue

as:

[insert information here]

Great care was taken to make these policies and procedures comprehensive and compliant with requirements and

recommendations from organizations such as OSHA, CDC, and the ADA. References to source information are

footnoted where appropriate.

Laws and recommendations from these organizations are numerous and subject to change. SNS cannot guarantee

this document complies with any federal or state laws. SNS also cannot accept responsibility if any information in

this document is in conflict with these laws. Before the policies and procedures in this document are implemented

at any dental clinic, we strongly encourage the organization to review federal and local laws and have policies and

procedures approved by health care professionals where appropriate.

2400 Computer Drive

Westborough, MA 01581

T: 508.329.2280

W:

P a g e |3

TABLE OF CONTENTS

Disclaimer .................................................................................................................................................................2

[INSERT NAME OF ORGANIZATION HERE] .....................................................................................................................8

Mission/Vision Statements .......................................................................................................................................9

Organizational Chart .................................................................................................................................................9

Principles of the Dental Practice ...............................................................................................................................9

Dental Services Provided ........................................................................................................................................10

Hours of Operation .................................................................................................................................................10

After-Hours Coverage .............................................................................................................................................10

PATIENT RIGHTS ..........................................................................................................................................................11

Posting of Notice of Patients¡¯ Rights .......................................................................................................................12

Patient Rights and Responsibilities .........................................................................................................................12

Our Commitment to Patients .................................................................................................................................14

Handling of Suspected Child Abuse Cases ..............................................................................................................15

CONFIDENTIALITY ........................................................................................................................................................17

Confidentiality.........................................................................................................................................................18

Sample Confidentiality Agreement .........................................................................................................................19

Release of Information ...........................................................................................................................................20

Sample Authorization to Release Patient Records .................................................................................................23

Informed Consent ...................................................................................................................................................24

Interpreter Services ................................................................................................................................................25

Patient Complaints/Incidents .................................................................................................................................26

REFERRALS ...................................................................................................................................................................29

Emergency Patients ................................................................................................................................................30

Specialty Services ....................................................................................................................................................31

Sample Patient Referral Form .................................................................................................................................32

SAFETY .........................................................................................................................................................................33

Medical Emergencies ..............................................................................................................................................34

Non-Emergency Situations .....................................................................................................................................36

Emergency Contact Information .............................................................................................................................37

Fire and Safety Plan ................................................................................................................................................39

2400 Computer Drive

Westborough, MA 01581

T: 508.329.2280

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Safety Management ................................................................................................................................................44

Sample Incident Report Form .................................................................................................................................45

Equipment Management ........................................................................................................................................47

Hazardous Materials Management ........................................................................................................................48

Emergency Preparedness Plan ................................................................................................................................49

Anaphylaxis .............................................................................................................................................................51

QUALITY MANAGEMENT .............................................................................................................................................53

Quality Management ..............................................................................................................................................54

GUIDELINES FOR COMPLETING THE QUARTERLY CHART REVIEW FORM ...............................................................62

QUARTERLY DENTAL CHART AUDIT TOOL ..............................................................................................................74

CLINIC OPERATIONS.....................................................................................................................................................76

Hours of Operation .................................................................................................................................................77

After-Hours Emergency Coverage ..........................................................................................................................77

Scope of Services Provided .....................................................................................................................................77

Scheduling ...............................................................................................................................................................78

Eligibility ..................................................................................................................................................................81

Prior Authorization .................................................................................................................................................82

Payment for Dental Care Policy ..............................................................................................................................83

Sample Declaration of Income Form ......................................................................................................................85

Sample Notice of Patient Responsibility for Payment for Dental Services .............................................................86

Broken Appointments .............................................................................................................................................87

Sample Missed Appointment Agreement ...............................................................................................................88

Sample Final Letter .................................................................................................................................................90

Emergency Patients ................................................................................................................................................91

Sample Triage Form ................................................................................................................................................93

Clinical Protocols .....................................................................................................................................................95

Sample Clinical Protocols ........................................................................................................................................98

Assessment of Vital Signs ......................................................................................................................................100

Guidelines for Patients Needing Antibiotic Prophylaxis .......................................................................................106

Dental Record Keeping .........................................................................................................................................109

Handling of Tissue Specimens ...............................................................................................................................113

Patient Education..................................................................................................................................................116

2400 Computer Drive

Westborough, MA 01581

T: 508.329.2280

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Patient Records .....................................................................................................................................................117

Retention of Dental Records .................................................................................................................................120

INFECTION CONTROL .................................................................................................................................................122

Infection Control Plan ...........................................................................................................................................123

Sample Infection Control Training Log ..................................................................................................................124

Federal Requirements...........................................................................................................................................125

The Purpose of Infection Control ..........................................................................................................................127

Employee Immunizations .....................................................................................................................................129

Engineering Controls .............................................................................................................................................130

Work Practice Controls .........................................................................................................................................131

Post-exposure management .................................................................................................................................132

Needle Sticks .........................................................................................................................................................134

American dental Association Post-Exposure Flow Chart ......................................................................................135

Work-Related Illnesses and Work Restrictions .....................................................................................................136

Personal protective equipment (PPE) ...................................................................................................................138

Hand Hygiene, Gloves, Nails, & Jewelry ................................................................................................................140

Latex hypersensitivity and Contact Dermatitis .....................................................................................................141

Sterilization and Disinfection of Patient-Care Items .............................................................................................143

Maintenance and Sanitation .................................................................................................................................144

Sterilization and Disinfection Methods .................................................................................................................147

Sterilization Monitoring ........................................................................................................................................151

Sample Sterilization Monitoring Log .....................................................................................................................152

Owner¡¯s Manuals for all equipment in Sterilization Area .....................................................................................153

Contract with Spore Testing Company .................................................................................................................153

AED & Emergency Kit Information ........................................................................................................................153

Infection Control In the Operatory .......................................................................................................................154

Medical Waste ......................................................................................................................................................156

Dental Unit Waterlines, Biofilm, Water Quality, and Boil-Water Advisories ........................................................159

Digital X-Ray Sensors, Intraoral Cameras, and High-Tech Instruments ................................................................161

Parenteral Medications ........................................................................................................................................161

Handling of Biopsy Specimens ..............................................................................................................................162

Infection Control In the Dental Laboratory...........................................................................................................163

2400 Computer Drive

Westborough, MA 01581

T: 508.329.2280

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