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-4762595885CLINICAL CHECK LIST*Review Evaluation PageReview Previous Notes/ Post-op Evaluation for existing clients“Daily Care Plan”ASSESSMENT PHASEInitial “Medical/Dental History& Cultural Life”(* include updated form) (12pages) – Signatures: DHS, Client & RDHNew 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 instructor1st appointment always requires ALL vitals to be takenUpdated Medical/ Dental History: Signatures: DHS, client & RDHVital Signs: Retake BP after 5 minutes if 1st reading is outside normal limits; Need Blood Glucose Level (BGL) readings for Diabetics“Medical Blood Pressure Consult” Forms (if required for hypertensive readings); “ Medical Clearance: Form (if required) – Signatures:RDH or DDSEnsure 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 & RDHSign up: RDH STOP!!-- CAN NOT PROCEED UNTIL ‘AUTHORIZED TO PROCEED’Complete “Radiographic Needs Assessment” form: Signature: DHS Initial “Radiographic Prescription”: Signature: DDS for RxClient 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 & DDSSign up: DDS (Can proceed)Dentist:Expose Rx’d Radiographs - Be observed if necessary – Ensure Quality Assurance is followedEnsure “Clinical Radiology Observation” sheets are completed by RDH- if required - [ ]1-FMS [ ]1-BW [ ]1-PAN: Signature: RDHMount on template from “Images”“Radiographic Interpretation” Signature: DDS “Referral” form if required – all areas to be complete – Signature: DDS & DHS“Caries Risk” assessment (assess for sealant recommendation, complete recommendation form as needed)Hard tissue charting – Signature: DDSUpdates at the3 or 4 month continuing care interval to be noted as [ ]change or [] no changes; any changes to be noted in the ROCNew forms to be used at the 6 plus month continuing care interval “Chart Audit” DHS & DDSSign up: DDS - Radiographic Interpretation & Hard Tissue Charting (Can proceed)IOE/EOE (2 pages):Photos – Use templates (12 for a new patient and 3 for a recall/existing client)Intra oral examExtra oral exam – Signature: RDHUpdates at the3 or 4 month continuing care interval to be noted as [ ]change or [] no changes; any changes to be noted in the ROCNew forms to be used at the 6+ month continuing care interval“Chart Audit” DHS & RDHSign up: RDH (Can proceed)Periodontal Assessment (4 pages): (Can NOT be evaluated without radiographs)“Initial Plaque Index”Complete probing and gingival margin line (GML). Calculate CAL & Bleeding Index. Determine AAP Classification.Assess DD level – Signature: RDHOTHERAlginate Impressions [ ]Study Model [ ]Whitening Tray [ ]Sportsguard“Chart Audit” DHS & RDHSign up: RDH (Can proceed)ASSESSMENT CHART AUDIT COMPLETED: Signature: RDHPLANNING PHASEDHD’s, CCG’s (#), DHI’s (must include ALL client deficiencies, goals and DH interventions such as debridement, polish, fluoride, alginates, sealants, referrals, nutritional analysis, tobacco cessation, whitening trays, sportsguard, OSC, etc...)Appointment sequencingInclude-- but not limited to the following: All interventions & OSC (be specific); 4 to 6 week re-eval appt’s; 2-week post-op appt for whitening, etc... Signature: DHS &CLIENTRefusals: Signature: Client “Chart Audit” DHS & RDHSTOP Sign up: RDHCANNOT PROCEED UNTIL VERIFICATION IS PROVIDED BY THE INSTRUCTOR.Signature: RDH Revisions: Signature: DHS & Client & RDHPLANNING CHART AUDIT COMPLETED: Signature: RDHIMPLEMENTATION PHASEAlginate Impressions [ ] Sportsguard [ ]Whitening TraySecond “Plaque Index” (Must be completed at the beginning of the last day/appt of debridement BEFORE the plaque is disturbed/removed) Start debridement (follow sequence in App’t Plan)Sign up: RDHDD1: two quads at a time (Q1,4 thenQ2,3) ; DD2/DD3: one quad at a time Q1 then Q4, then Q2 and Q3) ; DD4: sextants (S1, 2 then 6,5 then 3,4 or client specific)Sealants: Evaluation Signature: RDH or DDSShould 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 polish Sign up: RDH (Check with RDH if can proceed)Ensure “Clinical Competency Observation” sheets are completed by RDH- if required – [ ]1 polish: Signature: RDHFluoride Sign up: RDHEnsure “Clinical Competency Observation” sheets are completed by RDH- if required – [ ] 1-Fl Varnish: Signature: RDH “Transfer of Records” (if required)Post-Op photos (3 for all clients)Continuing Care Interval determined OTHERTobacco Cessation: Signature: RDH [ ] 24H Nutritional Analysis: Signature: RDH [ ] 3-Day Nutritional Analysis: Signature: RDHClient satisfaction “Exit Survey” Form“Chart Audit” DHS & RDHIMPLEMENTATION CHART AUDIT COMPLETED: Signature: RDHEVALUATION (Ongoing & Post Care)Complete chairside Post Care Evaluation (due last day of debridement)“Post Dental Hygiene” Form (Goals evaluated) Signature: DHS & RDH**Ensure to review the ROC prior to signing up for the Post CareEVALUATION CHART AUDIT COMPLETED: Signature: RDHCHAIRSIDE AUDIT COMPLETED DATE (bottom of page 3): Signature: DHS & RDHCLINICAL LEARNING REFLECTION JOURNAL“Clinical Learning Reflection Journal” (What I learned from this experience): Signature: RDH (to be completed within 5 business days)4-6 WEEK RE-EVAL: (TAKES AN HOUR TO AN HOUR AND A HALF)Med/dental history updates STOP! WAIT FOR AUTHORIZATION PRIOR TO PROCEEDINGReview all assessments – changes Plaque IndexFull mouth probe (Include Gingival Margin Line) (CAL & BI)Complete the 4 to 6 week reeval form Signature: DHS & RDHRe-assess OSC [ ] Debride (If necessary approx..20 minutes) [ ] Review Continuing Care Interval Chart Audit, pg 3 check off reeval, DHS & RDHSUBMIT Clinical Learning Reflection Journal (Sign up in Post-Care Folder )*Within business 5 days 483870030480“IF IT IS NOT WRITTEN – IT DID NOT HAPPEN”00“IF IT IS NOT WRITTEN – IT DID NOT HAPPEN”CONSIDERATIONS FOR ROCAuthorization to proceed (Written by RDH) Medical history (Initial or Updated)/ Dental/Cultural – Changes/Significant findingsMedical Consultation Form and/or Medical Clearance given to client re:___Optional: Systemic/ Med. Emg Conditions, Vital Signs; Allergies; Chief complaintClient 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 visitConsent 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 DDSRecords 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 clientTreatment 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__Subgingival Intrasulcular 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 localDebridement: Manual/ultrasonic debridement (deplaquing) of _area_ for _(duration/time)_ as per .(faculty name),_ R/RDHEvidence 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 whoAlginates – 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 recommendationsClient has a high _(sugar/fast food)_ consumption, nutrition counselling required/requested/refusedClient is a smoker for _(duration)_ with average _(frequency)_ / dayClient is willing/not contemplating to quit and tobacco cessation requested/refused.Client has quit smoking for _(duration)Polishing – grit, flavour used, timeSelective/full polish with fine/medium grit (bubblegum/mint flavour) completed for _(duration)_ minutesFluoride –product, method, time, post-op instructionsFluoride (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 minutesVarnish: Duraflur 5% NaFl varnish applied to __area__. Post op instructions: Do not brush teeth & avoid hard foods for 4 hours. After 4 hours remove varnish film by brushing. Any Post procedural rinses *(E.g.: 0.12% chlorhexidine for 2 minutes)Any Post-op instructions given (E.g.: Saline rinses, whitening procedures, sports guard, OTC meds)Postop picturesHow client tolerated appointment- Document any issue that arose during the appointment (tissue trauma, sensitivity, excessive bleeding, chipped tooth, medical emergency etc)Exit survey completedNext appointment: 4-6 re-eval, 3,6,9 month Continuing Care 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 ROCVerification 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 ................
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