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) ___
________________________________
|
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:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________
|
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:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________
|
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:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________
|
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:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________
|
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:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________
|
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:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________
|
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:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________
|
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:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________
|
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:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________
|
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:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________