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Procedural Evaluation Checklist

 

Protocol: One procedural checklist page is completed for each patient treated by the student. For Dalhousie Dental Clinic patients, the PATIENT ACTION PLAN/ TREATMENT PLAN form must be completed in this manual. At the NSCC Patient Clinic, the PATIENT ACTION PLAN/ TREATMENT PLAN is included in the patient chart documentation.

 

Students are being evaluated comprehensively on skills completed during patient treatment. The evaluation protocol for individual skills from the Preclinical I and II manuals are included in this manual for referral. Each procedure completed will be marked “S” for a satisfactory result, or “U” for an unsatisfactory result.

 

Students with more than three unsatisfactory results will be expected to have further preclinical practice, as discussed on page 5.

 

EXAMPLE: EVALUATION DOCUMENTATION

 

Patient Name or Chart #

WRITE PATIENT’S NAME or Chart #

Self-

Evaluation

Instructor

Evaluation

Instructors Comments:

Pre/Post Tx Room Set-Up and Disinfection

 

 

For Instructor’s use, to provide

Instrument Sterilization/Disinfection

 

 

comments or suggestions and

Vital Signs

 

 

information concerning grade

Oral Evacuation and/or Instrument Transfer

 

 

 

Oral Assessment

 

 

 

Topical Anesthetic and/or Assist with Local

 

 

 

Dental Dam

 

 

 

Preliminary Impression

 

 

 

Etc.

 

 

 

 

 

 

 

 

 

 

 

 

EXAMPLE: PATIENT ACTION PLAN/ TREATMENT PLAN

 

Action Taken _______ Placed dental dam ___________________ (WHAT) ____

Rationale_ _ Placed dental dam from 1-1 to 1-7_to prevent patient from swallowing materials / debris, maintain dry field when placing restoration__ ____ (WHY) ___




DALHOUSIE (Write in Patient Chart #)

 

________________________________

 

Self-

Evaluation

Instructor

Evaluation

Instructor’s Comments

Oral Evacuation and/or Instrument Transfer

 

 

 

Topical Anesthetic and/or Assist with Local

 

 

 

Dental Dam

 

 

 

Preliminary Impression

 

 

 

Simple Bite Registration

 

 

 

Amalgam Restoration

 

 

 

Composite Restoration

 

 

 

Dental Adhesives (etch/bond)

 

 

 

Treatment Liner or Varnish

 

 

 

Matrixes/ Wedges

 

 

 

Bases/Intermediate Restorations

 

 

 

Crown or Bridge Preparation

 

 

 

Final Impression Materials

 

 

 

Provisional Crown or Bridge

 

 

 

Temporary or Permanent Cement

 

 

 

Endodontic Treatment

 

 

 

Oral Surgery

 

 

 

Vital Signs

 

 

 

Suture Placement or Removal

 

 

 

Periodontal Treatment __________________

 

 

 

Periodontal Dressing

 

 

 

Removable Prosthodontics _______________

 

 

 

Implant(s), Stage ______________

 

 

 

Desensitizing Agent

 

 

 

Bitewing Radiographs or Images

 

 

 

Periapical Radiographs or Images

 

 

 

Professionalism /Appropriate Communication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Instructor_________________________ Date: _____________ Successful / Unsuccessful

 

Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________

 


PATIENT ACTION PLAN/ TREATMENT PLAN (Dalhousie Patient)

 

Patient Chart # _________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Notes:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 




DALHOUSIE (Write in Patient Chart #)

 

________________________________

 

Self-

Evaluation

Instructor

Evaluation

Instructor’s Comments

Oral Evacuation and/or Instrument Transfer

 

 

 

Topical Anesthetic and/or Assist with Local

 

 

 

Dental Dam

 

 

 

Preliminary Impression

 

 

 

Simple Bite Registration

 

 

 

Amalgam Restoration

 

 

 

Composite Restoration

 

 

 

Dental Adhesives (etch/bond)

 

 

 

Treatment Liner or Varnish

 

 

 

Matrixes/ Wedges

 

 

 

Bases/Intermediate Restorations

 

 

 

Crown or Bridge Preparation

 

 

 

Final Impression Materials

 

 

 

Provisional Crown or Bridge

 

 

 

Temporary or Permanent Cement

 

 

 

Endodontic Treatment

 

 

 

Oral Surgery

 

 

 

Vital Signs

 

 

 

Suture Placement or Removal

 

 

 

Periodontal Treatment __________________

 

 

 

Periodontal Dressing

 

 

 

Removable Prosthodontics _______________

 

 

 

Implant(s), Stage ______________

 

 

 

Desensitizing Agent

 

 

 

Bitewing Radiographs or Images

 

 

 

Periapical Radiographs or Images

 

 

 

Professionalism /Appropriate Communication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Instructor_________________________ Date: _____________ Successful / Unsuccessful

 

Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________

 


PATIENT ACTION PLAN/ TREATMENT PLAN (Dalhousie Patient)

 

Patient Chart # _________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Notes:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 


 

 



DALHOUSIE (Write in Patient Chart #)

 

________________________________

 

Self-

Evaluation

Instructor

Evaluation

Instructor’s Comments

Oral Evacuation and/or Instrument Transfer

 

 

 

Topical Anesthetic and/or Assist with Local

 

 

 

Dental Dam

 

 

 

Preliminary Impression

 

 

 

Simple Bite Registration

 

 

 

Amalgam Restoration

 

 

 

Composite Restoration

 

 

 

Dental Adhesives (etch/bond)

 

 

 

Treatment Liner or Varnish

 

 

 

Matrixes/ Wedges

 

 

 

Bases/Intermediate Restorations

 

 

 

Crown or Bridge Preparation

 

 

 

Final Impression Materials

 

 

 

Provisional Crown or Bridge

 

 

 

Temporary or Permanent Cement

 

 

 

Endodontic Treatment

 

 

 

Oral Surgery

 

 

 

Vital Signs

 

 

 

Suture Placement or Removal

 

 

 

Periodontal Treatment __________________

 

 

 

Periodontal Dressing

 

 

 

Removable Prosthodontics _______________

 

 

 

Implant(s), Stage ______________

 

 

 

Desensitizing Agent

 

 

 

Bitewing Radiographs or Images

 

 

 

Periapical Radiographs or Images

 

 

 

Professionalism /Appropriate Communication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Instructor_________________________ Date: _____________ Successful / Unsuccessful

 

Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________


PATIENT ACTION PLAN/ TREATMENT PLAN (Dalhousie Patient)

 

Patient Chart # _________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Notes:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 




DALHOUSIE (Write in Patient Chart #)

 

________________________________

 

Self-

Evaluation

Instructor

Evaluation

Instructor’s Comments

Oral Evacuation and/or Instrument Transfer

 

 

 

Topical Anesthetic and/or Assist with Local

 

 

 

Dental Dam

 

 

 

Preliminary Impression

 

 

 

Simple Bite Registration

 

 

 

Amalgam Restoration

 

 

 

Composite Restoration

 

 

 

Dental Adhesives (etch/bond)

 

 

 

Treatment Liner or Varnish

 

 

 

Matrixes/ Wedges

 

 

 

Bases/Intermediate Restorations

 

 

 

Crown or Bridge Preparation

 

 

 

Final Impression Materials

 

 

 

Provisional Crown or Bridge

 

 

 

Temporary or Permanent Cement

 

 

 

Endodontic Treatment

 

 

 

Oral Surgery

 

 

 

Vital Signs

 

 

 

Suture Placement or Removal

 

 

 

Periodontal Treatment __________________

 

 

 

Periodontal Dressing

 

 

 

Removable Prosthodontics _______________

 

 

 

Implant(s), Stage ______________

 

 

 

Desensitizing Agent

 

 

 

Bitewing Radiographs or Images

 

 

 

Periapical Radiographs or Images

 

 

 

Professionalism /Appropriate Communication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Instructor_________________________ Date: _____________ Successful / Unsuccessful

 

Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________

 


PATIENT ACTION PLAN/ TREATMENT PLAN (Dalhousie Patient)

 

Patient Chart # _________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Notes:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 




DALHOUSIE (Write in Patient Chart #)

 

________________________________

 

Self-

Evaluation

Instructor

Evaluation

Instructor’s Comments

Oral Evacuation and/or Instrument Transfer

 

 

 

Topical Anesthetic and/or Assist with Local

 

 

 

Dental Dam

 

 

 

Preliminary Impression

 

 

 

Simple Bite Registration

 

 

 

Amalgam Restoration

 

 

 

Composite Restoration

 

 

 

Dental Adhesives (etch/bond)

 

 

 

Treatment Liner or Varnish

 

 

 

Matrixes/ Wedges

 

 

 

Bases/Intermediate Restorations

 

 

 

Crown or Bridge Preparation

 

 

 

Final Impression Materials

 

 

 

Provisional Crown or Bridge

 

 

 

Temporary or Permanent Cement

 

 

 

Endodontic Treatment

 

 

 

Oral Surgery

 

 

 

Vital Signs

 

 

 

Suture Placement or Removal

 

 

 

Periodontal Treatment __________________

 

 

 

Periodontal Dressing

 

 

 

Removable Prosthodontics _______________

 

 

 

Implant(s), Stage ______________

 

 

 

Desensitizing Agent

 

 

 

Bitewing Radiographs or Images

 

 

 

Periapical Radiographs or Images

 

 

 

Professionalism /Appropriate Communication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Instructor_________________________ Date: _____________ Successful / Unsuccessful

 

Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________

 


PATIENT ACTION PLAN/ TREATMENT PLAN (Dalhousie Patient)

 

Patient Chart # _________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Notes:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 




DALHOUSIE (Write in Patient Chart #)

 

________________________________

 

Self-

Evaluation

Instructor

Evaluation

Instructor’s Comments

Oral Evacuation and/or Instrument Transfer

 

 

 

Topical Anesthetic and/or Assist with Local

 

 

 

Dental Dam

 

 

 

Preliminary Impression

 

 

 

Simple Bite Registration

 

 

 

Amalgam Restoration

 

 

 

Composite Restoration

 

 

 

Dental Adhesives (etch/bond)

 

 

 

Treatment Liner or Varnish

 

 

 

Matrixes/ Wedges

 

 

 

Bases/Intermediate Restorations

 

 

 

Crown or Bridge Preparation

 

 

 

Final Impression Materials

 

 

 

Provisional Crown or Bridge

 

 

 

Temporary or Permanent Cement

 

 

 

Endodontic Treatment

 

 

 

Oral Surgery

 

 

 

Vital Signs

 

 

 

Suture Placement or Removal

 

 

 

Periodontal Treatment __________________

 

 

 

Periodontal Dressing

 

 

 

Removable Prosthodontics _______________

 

 

 

Implant(s), Stage ______________

 

 

 

Desensitizing Agent

 

 

 

Bitewing Radiographs or Images

 

 

 

Periapical Radiographs or Images

 

 

 

Professionalism /Appropriate Communication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Instructor_________________________ Date: _____________ Successful / Unsuccessful

 

Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________

 


PATIENT ACTION PLAN/ TREATMENT PLAN (Dalhousie Patient)

 

Patient Chart # _________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Notes:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 




DALHOUSIE (Write in Patient Chart #)

 

________________________________

 

Self-

Evaluation

Instructor

Evaluation

Instructor’s Comments

Oral Evacuation and/or Instrument Transfer

 

 

 

Topical Anesthetic and/or Assist with Local

 

 

 

Dental Dam

 

 

 

Preliminary Impression

 

 

 

Simple Bite Registration

 

 

 

Amalgam Restoration

 

 

 

Composite Restoration

 

 

 

Dental Adhesives (etch/bond)

 

 

 

Treatment Liner or Varnish

 

 

 

Matrixes/ Wedges

 

 

 

Bases/Intermediate Restorations

 

 

 

Crown or Bridge Preparation

 

 

 

Final Impression Materials

 

 

 

Provisional Crown or Bridge

 

 

 

Temporary or Permanent Cement

 

 

 

Endodontic Treatment

 

 

 

Oral Surgery

 

 

 

Vital Signs

 

 

 

Suture Placement or Removal

 

 

 

Periodontal Treatment __________________

 

 

 

Periodontal Dressing

 

 

 

Removable Prosthodontics _______________

 

 

 

Implant(s), Stage ______________

 

 

 

Desensitizing Agent

 

 

 

Bitewing Radiographs or Images

 

 

 

Periapical Radiographs or Images

 

 

 

Professionalism /Appropriate Communication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Instructor_________________________ Date: _____________ Successful / Unsuccessful

 

Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________

 


PATIENT ACTION PLAN/ TREATMENT PLAN (Dalhousie Patient)

 

Patient Chart # _________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Notes:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 




DALHOUSIE (Write in Patient Chart #)

 

________________________________

 

Self-

Evaluation

Instructor

Evaluation

Instructor’s Comments

Oral Evacuation and/or Instrument Transfer

 

 

 

Topical Anesthetic and/or Assist with Local

 

 

 

Dental Dam

 

 

 

Preliminary Impression

 

 

 

Simple Bite Registration

 

 

 

Amalgam Restoration

 

 

 

Composite Restoration

 

 

 

Dental Adhesives (etch/bond)

 

 

 

Treatment Liner or Varnish

 

 

 

Matrixes/ Wedges

 

 

 

Bases/Intermediate Restorations

 

 

 

Crown or Bridge Preparation

 

 

 

Final Impression Materials

 

 

 

Provisional Crown or Bridge

 

 

 

Temporary or Permanent Cement

 

 

 

Endodontic Treatment

 

 

 

Oral Surgery

 

 

 

Vital Signs

 

 

 

Suture Placement or Removal

 

 

 

Periodontal Treatment __________________

 

 

 

Periodontal Dressing

 

 

 

Removable Prosthodontics _______________

 

 

 

Implant(s), Stage ______________

 

 

 

Desensitizing Agent

 

 

 

Bitewing Radiographs or Images

 

 

 

Periapical Radiographs or Images

 

 

 

Professionalism /Appropriate Communication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Instructor_________________________ Date: _____________ Successful / Unsuccessful

 

Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________

 


PATIENT ACTION PLAN/ TREATMENT PLAN (Dalhousie Patient)

 

Patient Chart # _________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Notes:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 




DALHOUSIE (Write in Patient Chart #)

 

________________________________

 

Self-

Evaluation

Instructor

Evaluation

Instructor’s Comments

Oral Evacuation and/or Instrument Transfer

 

 

 

Topical Anesthetic and/or Assist with Local

 

 

 

Dental Dam

 

 

 

Preliminary Impression

 

 

 

Simple Bite Registration

 

 

 

Amalgam Restoration

 

 

 

Composite Restoration

 

 

 

Dental Adhesives (etch/bond)

 

 

 

Treatment Liner or Varnish

 

 

 

Matrixes/ Wedges

 

 

 

Bases/Intermediate Restorations

 

 

 

Crown or Bridge Preparation

 

 

 

Final Impression Materials

 

 

 

Provisional Crown or Bridge

 

 

 

Temporary or Permanent Cement

 

 

 

Endodontic Treatment

 

 

 

Oral Surgery

 

 

 

Vital Signs

 

 

 

Suture Placement or Removal

 

 

 

Periodontal Treatment __________________

 

 

 

Periodontal Dressing

 

 

 

Removable Prosthodontics _______________

 

 

 

Implant(s), Stage ______________

 

 

 

Desensitizing Agent

 

 

 

Bitewing Radiographs or Images

 

 

 

Periapical Radiographs or Images

 

 

 

Professionalism /Appropriate Communication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Instructor_________________________ Date: _____________ Successful / Unsuccessful

 

Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________

 


PATIENT ACTION PLAN/ TREATMENT PLAN (Dalhousie Patient)

 

Patient Chart # _________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Notes:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 


 



DALHOUSIE (Write in Patient Chart #)

 

________________________________

 

Self-

Evaluation

Instructor

Evaluation

Instructor’s Comments

Oral Evacuation and/or Instrument Transfer

 

 

 

Topical Anesthetic and/or Assist with Local

 

 

 

Dental Dam

 

 

 

Preliminary Impression

 

 

 

Simple Bite Registration

 

 

 

Amalgam Restoration

 

 

 

Composite Restoration

 

 

 

Dental Adhesives (etch/bond)

 

 

 

Treatment Liner or Varnish

 

 

 

Matrixes/ Wedges

 

 

 

Bases/Intermediate Restorations

 

 

 

Crown or Bridge Preparation

 

 

 

Final Impression Materials

 

 

 

Provisional Crown or Bridge

 

 

 

Temporary or Permanent Cement

 

 

 

Endodontic Treatment

 

 

 

Oral Surgery

 

 

 

Vital Signs

 

 

 

Suture Placement or Removal

 

 

 

Periodontal Treatment __________________

 

 

 

Periodontal Dressing

 

 

 

Removable Prosthodontics _______________

 

 

 

Implant(s), Stage ______________

 

 

 

Desensitizing Agent

 

 

 

Bitewing Radiographs or Images

 

 

 

Periapical Radiographs or Images

 

 

 

Professionalism /Appropriate Communication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Instructor_________________________ Date: _____________ Successful / Unsuccessful

 

Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

 

PATIENT ACTION PLAN/ TREATMENT PLAN (Dalhousie Patient)

 

Patient Chart # _________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

Action Taken _________________________________________________________

Rationale ____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Action Taken _________________________________________________________

Rationale_____________________________________________________________

 

 

Notes:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

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