Documentation for Other Clinic Experiences
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Self- Evaluation |
Instructor Evaluation |
Instructor’s Comments |
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Vital Signs |
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Oral Evacuation and/or Instrument Transfer |
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Oral Assessment |
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Oral Hygiene Instruction |
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Coronal Polishing |
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Topical Fluoride |
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Bitewing Radiographs or Images |
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Periapical Radiographs or Images |
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Panoramic Image |
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Pit and Fissure Sealant |
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Desensitizing Agent |
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Overall Patient Treatment Evaluation |
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Safety measures followed |
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Infection control protocols followed |
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Demonstrates professionalism and appropriate communication skills |
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Instructor:_________________________ Date: _____________ Successful / Unsuccessful
Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________
PATIENT ACTION PLAN/ TREATMENT PLAN
Patient Chart # _________________________________
Action Taken _________________________________________________________
Rationale ____________________________________________________________
Action Taken _________________________________________________________
Rationale ____________________________________________________________
Action Taken _________________________________________________________
Rationale_____________________________________________________________
Notes:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(Write in Patient Chart #)
________________________________ |
Self- Evaluation |
Instructor Evaluation |
Instructor’s Comments |
|
Vital Signs |
|
|
|
|
Oral Evacuation and/or Instrument Transfer |
|
|
|
|
Oral Assessment |
|
|
|
|
Oral Hygiene Instruction |
|
|
|
|
Coronal Polishing |
|
|
|
|
Topical Fluoride |
|
|
|
|
Bitewing Radiographs or Images |
|
|
|
|
Periapical Radiographs or Images |
|
|
|
|
Panoramic Image |
|
|
|
|
Pit and Fissure Sealant |
|
|
|
|
Desensitizing Agent |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
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|
Overall Patient Treatment Evaluation |
|||
|
Safety measures followed |
|
|
|
|
Infection control protocols followed |
|
|
|
|
Demonstrates professionalism and appropriate communication skills |
|
|
|
Instructor:_________________________ Date: _____________ Successful / Unsuccessful
Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________
PATIENT ACTION PLAN/ TREATMENT PLAN
Patient Chart # _________________________________
Action Taken _________________________________________________________
Rationale ____________________________________________________________
Action Taken _________________________________________________________
Rationale ____________________________________________________________
Action Taken _________________________________________________________
Rationale_____________________________________________________________
Notes:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(Write in Patient Chart #)
________________________________ |
Self- Evaluation |
Instructor Evaluation |
Instructor’s Comments |
|
Vital Signs |
|
|
|
|
Oral Evacuation and/or Instrument Transfer |
|
|
|
|
Oral Assessment |
|
|
|
|
Oral Hygiene Instruction |
|
|
|
|
Coronal Polishing |
|
|
|
|
Topical Fluoride |
|
|
|
|
Bitewing Radiographs or Images |
|
|
|
|
Periapical Radiographs or Images |
|
|
|
|
Panoramic Image |
|
|
|
|
Pit and Fissure Sealant |
|
|
|
|
Desensitizing Agent |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Overall Patient Treatment Evaluation |
|||
|
Safety measures followed |
|
|
|
|
Infection control protocols followed |
|
|
|
|
Demonstrates professionalism and appropriate communication skills |
|
|
|
Instructor:_________________________ Date: _____________ Successful / Unsuccessful
Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________
(Write in Patient Chart #)
________________________________ |
Self- Evaluation |
Instructor Evaluation |
Instructor’s Comments |
|
Vital Signs |
|
|
|
|
Oral Evacuation and/or Instrument Transfer |
|
|
|
|
Oral Assessment |
|
|
|
|
Oral Hygiene Instruction |
|
|
|
|
Coronal Polishing |
|
|
|
|
Topical Fluoride |
|
|
|
|
Bitewing Radiographs or Images |
|
|
|
|
Periapical Radiographs or Images |
|
|
|
|
Panoramic Image |
|
|
|
|
Pit and Fissure Sealant |
|
|
|
|
Desensitizing Agent |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Overall Patient Treatment Evaluation |
|||
|
Safety measures followed |
|
|
|
|
Infection control protocols followed |
|
|
|
|
Demonstrates professionalism and appropriate communication skills |
|
|
|
Instructor_________________________ Date: _____________ Successful / Unsuccessful
Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________
PATIENT ACTION PLAN/ TREATMENT PLAN
Patient Chart # _________________________________
Action Taken _________________________________________________________
Rationale ____________________________________________________________
Action Taken _________________________________________________________
Rationale ____________________________________________________________
Action Taken _________________________________________________________
Rationale_____________________________________________________________
Notes:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
