The purpose of this review is to assess the quality of each clinical facility with an emphasis on measures taken in the area of infection control. The format is to be used for both health center and school clinics and the standards noted in each criterion are to be used as a guide for the evaluation.

The key to evaluating each element of the clinic is determined by how well each element or protocol meets accepted standards. If it meets reasonable standards, then it should be judged as either acceptable (noted as either acceptable or yes). If the element or protocol is deficient OR nonexistent, then it should be judged as not acceptable (noted as not acceptable or no). All negative ratings must be explained in the COMMENTS section of each table.


A. Staff on Duty

List the names of all staff present during the review.

B. Personal Appearance

  1. A clean uniform is defined as one that is not soiled. Take into consideration that a laundered uniform can be stained but is still clean.
  2. Evaluate the cleanliness of each of the staff for the following: hands, face, fingernails, hair, mouth. Also be aware of body odors, mouth odors, unkempt hair, and soiled and wrinkled street clothes.


A. Cleanliness

Evaluate the cleanliness of the treatment area. To grade the cleanliness of the dental units and patient chair, assess these between patients; not during patient care. Any area that is dusty, smudged with dirt, or soiled with blood or debris is graded as not clean.5/30/07

This section, with the exception of the condition of the cushion of the patient chair, will use a rating of three; a rating of (1) means that the equipment or element of the facility is fully operable, a rating of (2) means that the equipment is marginally operable but imposes a burden on the user, and a rating of (3) means that the equipment is nonfunctional/inoperable. If a piece of equipment functions with even the smallest impairment, it should be rated a (2).

  1. Check the operability of the components of the dental units. Run the handpieces to determine the appropriate torque. An adequate low speed suction should empty a three ounce cup in less than 5 seconds if fully operable. Query the staff concerning problems with the unit.
  2. Review the condition of the chair. A large break is defined as more than one half inch long. Check the headrest and tilt mechanism and determine their operability.
  3. Review the operability of the remainder of the equipment in the clinic. Discuss the adequacy of their function with the staff.


Check YES if all protocols are followed; check NO if protocols are either incompletely executed or if not followed.

  1. Confirm that a current permit is displayed.
  2. Verify that a lead with a cervical collar is used on patients during the taking of all radiographs.
  3. Verify that all clinic staff has a radiation control badge on person – whether pinned on a uniform or gown or in a pocket. 5/30/07g of radiographs or that the person taking them stands at least six feet from the patient’s head per the city code.
  4. Check the processing solutions in both the standard processing tanks and in the automatic processors. Note if there is a posting on the wall for dates of the changing of the solutions.


Evaluate each component using the infection controls protocols as a guide. Check acceptable if the element reviewed adheres to the protocols; check not acceptable if the element is either judged to be deficient or missing.


Check YES if the criterion is met; check NO if a criterion is judged to be deficient or is missing.

  1. Check acceptable if the supply area is well organized and accessible. This criterion is unacceptable if supplies are scattered throughout the clinic.
  2. Check for the neatness and cleanliness of the inventory area.
  3. Check if the storage area in the health center has a lock and an available key. Ask if the storage area is locked when the clinic is closed.
  4. All clinics must maintain a chronological file of all supply order forms in order to monitor supplies. If this file is not present, not in chronological order, or not prope 5/30/07
  5. Check for any expired materials on the shelves.


Check YES if each element of the appointment system is completed as required in all forms reviewed; check NO if any element is either not performed/completed or if missing on one or more forms reviewed.

  1. Review past and future scheduling sheets to determine completeness in filling out these sheets. Note that DISPOSITION OF VISIT identifies whether the appointment was (1) kept, (2) missed, or (3) the patient was seen on a walk-in basis.
  2. Verify if flexible appointment times are used, i.e., short appointments for post-op procedures and longer appointments for endodontic procedures.
  3. Determine if a recall system is in place and if it is utilized.
  4. Determine if there is any follow-up procedures for missed appointments either by telephone or mailings.
  5. Check if appointment reminders are made either by postcard or by phone. Evaluate if the appointment scheduling sheet notes that reminders are made (that there is a check in the REMINDER column denoting the execution of reminders).


Use the criteria for the previous sections to determine the status of each variable.

  1. Review the system for delivering dental records in a timely manner to the dental clinic. Records should be available prior to the onset of each patient session so that the providers can review these and so appointed patient do not have to wait for the record.
  2. Determine the time it takes to receive a record after a patient enters the dental clinic for emergency treatment. The time should not exceed one-half an hour.


Use the criteria for the previous section to determine the status of each variable.

  1. Determine if a formal referral system is utilized for medical and dental specialty referrals. If YES, then answer the following two criteria.
  2. Check if there is a folder that maintains copies of all referral forms. Forms must be kept in chronological order. If it is not present, check NO.
  3. Review referral forms for completeness: check all forms in the file. Check NO if one of the following is missing from a form:
    • Dentist name and address
    • Name of referral site or individual provider
    • Patient name, address, and telephone number
    • Reason for the referral