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[Facility]
Dental Policy and Procedure Manual Template
This document is a template for you to construct a comprehensive dental policy and procedure manual. This document CANNOT be used as is. You must examine each procedure and match the policy to your practices.
Throughout the document you will see type in Bold and type in italics. Bold type usually means you must insert a specific name (facility, department, individual or State). Italicized type usually indicates an example.
Check each policy for your facility’s unique requirements and practices.
Many policies are based on professional organizations’ recommendation s or guidelines. Those policies include a statement such as:
This facility adheres to the [Organization] guidelines for [topic]. According to the [organization’s] [Year] [position, policy or clinical guidelines]:

You may elect to include this statement and then use the entire recommendation or guideline in quotes.

It is recommended you use the authoritative source whenever possible. You may use the above statement and simply insert your facility’s name, the topic, the organization, date and type of recommendation in the bold sections.

For more information or assistance in using this document contact:

M. Catherine Hollister, RDH, MSPH, PhD

Director-Nashville Area Dental Support Center

United South and Eastern Tribes, Inc.

711 Stewarts Ferry Pike

Nashville, TN  37214

mary.hollister@ihs.gov
Original Template: 2009

Revised: 2012

Acknowledgements:
Thanks to all of the dental programs and individuals who have contributed to this document. Those who have contributed enitre policies, statements, recommendations or assisted in revising or editing include:


Joyce Biberica, DDS, MS

Cherokee Indian Hospital Authority


Harry Brown, MD

Nashville Area Office


Cherokee Indian Hospital Authority

Dental Policy and Procedures Manual


Kit Grosch, MPH

Nashville Area Office


Cathy Hollister, RDH, MSPH, PhD

United South and Eastern Tribes, Inc.


Byron Jasper, DDS

United South and Eastern Tribes, Inc


Dana Johnson DDS

Passamaquoddy Indian Township Health Center


Northern Navajo Medical Center

Shiprock, NM


John Otteson, DDS

Oneida Nation Health Center


Pat Planck, RDH

Oneida Nation Health Center


Nick Porcello

Lionel R. John Health Center

Seneca Nation


Tim Ricks, DDS, MPH

Nashville Area Office


Jeffrey Stuart, DDS

Catawba Health Center


Michael Vito, DDS

Cattauagus Health Center

Seneca Nation


.


Sample Policy Authorization Formats
Single Title Page to cover all policies

[Tribe or Facility] Dental

Policies and Procedure Manual




Policy/Procedure Type:

Administrative

□ Interdepartmental

 Departmental



Department(s): Dental





Effective Date:

Revision Date: Supersedes:






Signatures:

___________________________/_____________

Date

___________________________/_____________



Date

___________________________/_____________

Date










Header for each individual policy

Policy & Procedure Statement


Subject: Policy Name
Effective Date:

Revision Date:

Supersedes:
P&P Number: A.1
Signatures:

Table of Contents
Sample Title Page with Signatures 3

Section A: Administration

A.1. Dental Program Policies and Procedures 6

A.2. Organizational Chart 9

A.3. Dental Program Summary 10

A.4. New Employee Orientation 12

A.5. Ordering/Requisitioning Supplies 15

A.6. Privileging/Credentialing 16

A.7. Documentation 17

A.8. Pain Documentation 19

A.9. Medical Records 22

A.10. Staff Assignments and Duties 23

A.11. Staff Training 24

A.12. Students, Trainees and Volunteers 25

A.13. Leave 28

A.14. Dress Code 30

A.14. Patient Satisfaction 31


Section B: Clinical Services
B.1. Appointment Procedures 34

B.2. After Hours, Emergency Dental Care, and Triage 37

B.3. On Call 40

B.4. Guidelines for Prenatal Oral Health Care 41

B.5. Intoxicated Persons 42

B.6. Standing Orders for Dental Auxiliary Staff 43

B.7. Medical History 44

B.8. Schedule of Services 46

B.9. Completed Treatment 51

B.10. Referral Procedures 52

B.11. Dental Laboratory 54

B.12. Protective Stabilization 56

B.13. Caries Stabilization 58

B.14. Informed Consent 59

B.15. Radiography 61

B.16. Pharmacy/Prescriptions 66

B.17. Dental Pain Management 67

B.18. Pharmacological Management of Oral Infections 78

B.19. Extracted Teeth 84

B.20. Hypertension Screening and Treatment Guidelines 85

B.21. Premedication to Prevent Infective Endocarditis 86

B.22. Premedication for Patients with Complete Joint Replacement 89

B.23. Medical Emergencies in the Dental Clinic 96

B.24. Reporting Domestic Violence 99

B.25. Pathology 101

B.26. Clinical Oral Disease Prevention/Health Promotion 102

B.27. Nitrous Oxide 103

B.28. Conscious Sedation 108


Section C: Environment
C.1. Infection Control 119

C.2. Radiological Protection 135

C.2. Equipment Maintenance and Product Recalls 136

C.3. Nitrous Oxide Safety 136

C.4. Fire Plan 139

C.5. Mercury Hygiene 140

C.6. Safety 144

C.7. Precious Metal Recovery 146

C.8. Hazardous Communications 147
Section D: Quality Assurance
D.1. Continuous Quality Improvement (Clinical) 174

D.2. Risk Management/Program Monitoring 177

Program Monitoring Tool 178

Sample Employee Training Tracking Form 194

Sample Facility Review Tracking Form 195

Section E: Community Health
E.1. Community Health Promotion/Disease Prevention 196

E.2. Head Start/Preschool 199

E.3. Infection Control for Portable Settings 200

E.4. Oral Health Surveillance 202




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