Unit 3.

1a Clinical Assessment (Examination / Oral Health Assessment)

1. New Patient /

• A patient with existing /past treatment and treatment MUST be selected

Section 1

Set up
Write everything you wrote in Unit 1.1a ‘Preparing and maintaining”
 List all the instruments// items needed for Check Up procedure including patient items)

Section 1
Patient details: Please add all points below:
 Male or female
 Age
 Medical history – date completed, medical conditions and medicaments

 Smoker or non-smoker - how many per day?

 Alcohol units drunk per week?
 When did they last see a Dentist ? (i.e. The patient last seen a dentist 6 months ago for a check up)
 List all treatment previously received – (UR6 MO amalgam filling, UR8 missing, etc”)
 State results of BPE in sextants (BPE was 010, 111)
 Describe soft tissue assessment : Soft tissue–cancer screen, TMJ check ( the dentist examined the soft
tissue and assessed for oral cancer, he also checked TMJ, everything was fine).

Section 2
you MUST select a patient needing several items of treatment
 Did you use UK (Palmers) or FDI notation?
 List the items of treatment needed. Be specific – tooth, surfaces etc (eg i.e I did UK charting on
the computer, dictated by the dentist: LL7 MO filling needed, LR8 to be extracted, etc)

 Did you notice and changes in the patient’s oral health status and take any appropriate action? (e.g I
noticed the patient’s gums were inflamed and red”)

Patient care
 Helping with any bags or coat? Any communication?
 Made sure they are sitting confortably, placed bib etc.
 How you monitored them for signs of emergencies? What emergencies? List please

Support for Dentist

 Checking overhead light is in correct position
 Passing anything ? what did you pass to the dentist? (I brought the xray tube closer to patient, turned
on the xray machine and set up the computer for taking the xray)
 -developed the xray and saved it in the patient’s records.
 After the procedure I removed bib and goggles, made sure patient’s face was clean and escorted patient to
 the reception to book the next appointment for filling. Then I said goodbye.

Clean up. Briefly say:

 How you transported used items to the dirty zone
 That you cleaned and sterilised them (no need to say how)
 Waste disposal – what and where
 Which surfaces you cleaned/disinfected

Reflection
 Strength
 Weakeness
 Action
Make sure you write the declaration below otherwise your PERS will be returned
I confirm that patient consent was gained for a trainee dental nurse to assist the clinician prior to treatment.

Unit 3.1b Clinical Assessment (Examination / Oral Health Assessment)

Existing patient

A patient with existing /past treatment and treatment MUST be selected (you
cannot say that patient didn’t need any treatment)

Section 1

Set up
Write everything you wrote in Unit 1.1a ‘Preparing and maintaining”
List all the instruments// items needed for Check Up procedure including patient items)

Section 1
Patient details: Please add all points below:
 Male or female
 Age
 Medical history – date completed, medical conditions and medicaments

 Smoker or non-smoker - how many per day?

 Alcohol units drunk per week?
 When did they last see a Dentist ? (i.e. The patient last seen a dentist 6 months ago for a check up)
 List all treatment previously received – (UR6 MO amalgam filling, UR8 missing, etc”)
 State results of BPE in sextants (BPE was 010, 111)
 Describe soft tissue assessment : Soft tissue–cancer screen, TMJ check ( the dentist examined the soft
tissue and assessed for oral cancer, he also checked TMJ, everything was fine).
Section 2
you MUST select a patient needing several items of treatment
Did you use UK (Palmers) or FDI notation?
List the items of treatment needed. Be specific – tooth, surfaces etc (eg i.e I did UK charting on the
computer, dictated by the dentist: LL7 MO filling needed, LR8 to be extracted, etc)

Did you notice and changes in the patient’s oral health status and take any appropriate action? (e.g I noticed
the patient’s gums were inflamed and red”)

Patient care
Helping with any bags or coat? Any communication?
Made sure they are sitting confortably, placed bib etc.
How you monitored them for signs of emergencies? What emergencies? List please

Support for Dentist

Checking overhead light is in correct position
Passing anything ? what did you pass to the dentist? (I brought the xray tube closer to patient, turned on the
xray machine and set up the computer for taking the xray)
-developed the xray and saved it in the patient’s records.
After the procedure I removed bib and goggles, made sure patient’s face was clean and escorted patient to the
reception to book the next appointment for filling. Then I said goodbye.

Clean up. Briefly say:

How you transported used items to the dirty zone
That you cleaned and sterilised them (no need to say how)
Waste disposal – what and where
Which surfaces you cleaned/disinfected

Reflection
Strength
Weakeness
Action
Make sure you write the declaration below otherwise your PERS will be returned
I confirm that patient consent was gained for a trainee dental nurse to assist the clinician prior to treatment.

Unit 3.1c Clinical Assessment (Emergency patient)

Section 1

Set up
Write everything you wrote in Unit 1.1a ‘Preparing and maintaining”
 List all the instruments// items needed for emergency patient procedure including patient items)
Section 1
Patient details: Please add all points below:
 Gender, age
 Smoker or non-smoker - how many per day?
 Alcohol units drunk per week?
 When did they last see a Dentist ? (i.e. The patient last seen a dentist 6 months ago for a check up)


Section 2
you MUST say why was this an emergency patient? (crown came off, filling came out, dental abcess, pain, extraction needed)
Did the dentist take any xrays? What , why? What he discovered?
 List the treatment needed. Be specific – tooth, surfaces etc LR8 to be extracted, etc)

 Did you notice and changes in the patient’s oral health status and take any appropriate action? (e.g I
noticed the patient’s gums were inflamed and red”, or “the patient crown was missing.)

Patient care
 Helping with any bags or coat? Any communication?
 Made sure they are sitting confortably, placed bib etc.
 How you monitored them for signs of emergencies? What emergencies? List please

Support for Dentist

 Checking overhead light is in correct position
 Passing anything ? what did you pass to the dentist? (I brought the xray tube closer to patient, handed
over the xray holder to dentist, turned on the xray machine and set up the computer for taking the
xray)
 -developed the xray and saved it in the patient’s records.
 After the procedure I removed bib and goggles, made sure patient’s face was clean and escorted patient to
the reception to book the next appointment. If patient came in with pain then you can describe how the
dentist extirpated the pulp then put a temporary filling. Then he asked the patient to come back for a RCT
(root canal treatment)
 Then I escorted patient to reception and made sure he booked the appointment.
 Then I said goodbye.

Clean up. Briefly say:

 How you transported used items to the dirty zone
 That you cleaned and sterilised them (no need to say how)
 Waste disposal – what and where
 Which surfaces you cleaned/disinfected

Reflection
 Strength
 Weakeness
 Action
Make sure you write the declaration below otherwise your PERS will be returned
I confirm that patient consent was gained for a trainee dental nurse to assist the clinician prior to treatment.