Operatory Set-up/Tear Down Protocol Checklist

Operatory Set-up/Tear Down Protocol Checklist
Date

MonthDayYear
Date
Student Name
Directions

This form is to be utilized to perform operatory set up and tear down duties. Proper performance of these duties is critical to safe patient treatment, operator safety, and equipment care. The student is expected to follow ALL task guidelines.
OPERATORY SET-UP
Arrival and Two Step Hand Hygiene:
Two Step Hand Hygiene Part 1: beginning with Hand Wash: Duration 40-60 seconds
Two Step Hand Hygiene Part 2: Perform Hand Rub: Duration 20-30 seconds
PPE Placement and Initial Operatory Preparation:
Unit Preparation for Patient Treatment:
Set up Operatory for Treatment GATHER BARRIERS AND APPLY:
PATIENT TREATMENT AND DISMISSAL PROTOCOL
Seat the Patient - Be mindful of glove use
During Treatment
Radiographic Image Acquisition ****To be used during rad lab
Patient Dismissal
END OF CLINIC SESSION
Operatory Breakdown and Disinfection
Completion of Session Duties:
Comments:
Should be Empty:

Directions