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Statium Sterilizer
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COMMENTS |
PERFORMED ON |
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1. Spray items with disinfectant
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2. Ultrasonic items
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3. Rinse and dry items
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4. Check solution reservoir
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5. Turn power on
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6. Open cassette
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7. Load instruments DO NOT OVERLOAD
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8. Place chemical indicator in cassette
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9. Close the lid
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| 10.Insert cassette into unit
until it clicks |
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11. Press the button for desired cycle
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| 12. Press START |
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13. Amber light flashes upon completion
( will hear chirping sound)
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14. Successful cycle will display "STERILIZED" |
A= (2 points) Acceptable Performed On: __Faculty (SVI)
I = (1 point) Improvable ( P ) Peer __Intern/Externship Site
X =(0 points) Unacceptable ( C ) Clinical Patient __Clinical Instructor (SVI)
*Must be performed at "A" level
GRADE:_________ DATE:___________ INSTRUCTOR/TITLE:________________
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Clinic Evaluation Final
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COMMENTS |
PERFORMED ON |
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1. Aseptic technique maintained
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2. Selection adjustment of chair
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3. Illumination maintained
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4. Retraction utilized as needed
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5. Oral cavity rinsed, evacuated, and dried when
appropriate |
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6. Instruments correctly place on tray
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7. Pick up and ready instrument #1
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8. Pass instrument #1
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9. Receive instrument #1
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10. Replace instrument #1
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11. Pick up and ready instrument #2
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12. Pass instrument #2
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13. Receive instrument #2 on tray
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14. Replace instrument #2 on tray
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15. Ready hand piece for transfer
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16. Transfer hand piece/Receive hand piece
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17. Patient safety maintained
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A= (2 points) Acceptable Performed On:
I= (1 point) Improvable ( P ) Peer
X=(0 points) Unacceptable ( C ) Clinical Patient
*Must be performed at "A" level ( X ) Xternship
GRADE:________________________ DATE:______________________
INSTRUCTOR:_____________________
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Cold Sterilization
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A |
I |
X |
COMMENTS |
PERFORMED ON |
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1. Spray items with disinfectant
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2. Ultrasonic items
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3. Rinse items
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4. Place items in sterilization
solution |
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5. Proper sterilization time*
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6. Rinse with distilled water
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7. Dry & Store
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8. Maintain aseptic technique*
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9. Student’s appearance
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A= (2 points) Acceptable Performed On:
I = (1 point) Improvable ( P ) Peer
X =(0 points) Unacceptable ( C ) Clinical Patient
* Must be performed at "A" level ( X ) Xternship
GRADE:___________ DATE:_____________ INSTRUCTOR:________________
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Heat Sterilization
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A |
I |
X |
COMMENTS |
PERFORMED ON |
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1. Spray items with disinfectant
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2. Ultrasonic items
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3. Rinse and dry items
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4. Check solution reservoir
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5. Turn knob to fill
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6. Turn knob to sterilize
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7. Load instruments
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8. Close door
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9. Set controls
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| 10. Sterilize items |
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11. Remove items
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| 12. Maintain
aseptic |
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13. Appearance of student
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A= (2 points) Acceptable Performed On:
I = (1 point) Improvable ( P ) Peer
X =(0 points) Unacceptable ( C ) Clinical Patient
*Must be performed at "A" level ( X ) Xternship
GRADE:_________ DATE:___________ INSTRUCTOR:______________________
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FRONT DESK OFFICE COMPETENCY
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COMMENTS |
PERFORMED ON |
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1 . Appearance |
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2. Professionalism
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VERBAL COMMUNICATION |
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1. Answering Phone
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2. Greeting Patients |
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3. Establish Patients |
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4. Confirming Appointments |
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5. Taking Massages |
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6. Changing Telephone Greeting
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MAINTAIN PATIENT INFORMATION |
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1. Create: New File |
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2. Day Schedule/Daily |
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3. Confirming Appointments |
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4. Handling No Shows, and
cancellations |
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5. Recalls and reschedules |
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Computer Skills |
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1. Set-Up Patient’s File |
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2. Set-Up Day Schedule |
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3. Billing |
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4. Rx |
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5. Transfer |
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6. Payments |
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7. Print Outs |
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MISCELLANEOUS |
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1. Maintaining Waiting Room |
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2. Pulling Files |
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3. Keeping files in Alpha. order |
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4. Escorting patients down for
payment |
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A= (2 points) Acceptable Performed On: __Faculty (SVI)
I = (1 point) Improvable ( P ) Peer __Intern/Externship Site
X =(0 points) Unacceptable ( C ) Clinical Patient __ Clinical Instructor
(SVI)
*Must be performed at "A" level
GRADE:_________ DATE:___________ INSTRUCTOR/TITLE:________________
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