State College of Florida
Dental Hygiene Program
Evaluation Form for Clinical Practice IV
Patient Complete?
No
Yes
Patient Information
Student Initials
*
First & Last Initial
Patient Information
*
Identification Number
Patient Category:
*
Child (6-11 yo)
Adolescent(12-18yo)
Adult(19-64yo)
Geriatric(65+yo)
Ethnic Origin:
*
Caucasian
African American
Hispanic
Asian
Native American
Other
Maintenance
*
Yes
No
(Recall to the student)
Special Needs
*
Yes
No
Type of Special Need(s):
DH Deposit
0
I
II
III
IV
SRP
Yes
No
Recall
6 week
3 month
4 month
6 month
Perio Stage
Healthy
Gingivitis
Initial (Stage I)
Moderate (Stage II)
Severe (Stage III)
Advanced (Stage IV)
TBD
Perio Grade
Slow Rate (A)
Moderate Rate (B)
Rapid Rate (C)
Treatment Experiences
Rows
Date
Date
Date
Date
Date
Date
Ultrasonic
Piezo
Intra Oral Camera
Diet Survey 1
Diet Survey 2
Phase Microscope
Sealants
Air Polisher- Subgingival
Air Polisher- Supragingivial
Local Anesthesia Administration
Oraqix
Arestin
VELscope
Notation for experiences listed above:
Ultrasonic Utilization with treatment
Please Select
Approved prior to scaling
Approved for Lavage
Not Approved
Determined for deposit 0/I/II patients
Patient Dismissed
Date
Reason
Comments:
Performance Evaluation
Rows
1st
2nd
3rd
4th
5th
6th
Grade
1. Medical / Dental Histories / Patient Assessment - 30 points
* -1pt for each minor error
* -5pts for each major error
2. Instrumentation/Scaling - 40 points
* -4pts per surface for residual calculus or lack of subgingival biofilm removal
* +1pt gain per surface if the student removes calculus on second attempt
* -5pts per surface for incorrect instrumentation resulting in overworked tissue, and/or tissue trauma
3. Biofilm / Stain Removal - 5 pts
* -.5pt per tooth for residual plaque/stain
* -1pt deduction per surface -incorrect instrumentation and tissue trauma
4. Professionalism - 25 pts
* Point deductions range from -1 to -10
Final Grade:
Credit or No Credit
Students who have met requirements
Medical History, HTE/STE, Assessment Comments:
Instrumentation/Scaling
Polishing
Date
-
Month
-
Day
Year
Date
Professionalism Comments:
Instructor Check In/Out
Submit
Should be Empty: