Bold and type in italics. Bold

Download 1.46 Mb.
Date conversion17.11.2016
Size1.46 Mb.
  1   2   3   4   5   6   7   8   9   ...   28
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
Original Template: 2009

Revised: 2012

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:


□ Interdepartmental

 Departmental

Department(s): Dental

Effective Date:

Revision Date: Supersedes:








Header for each individual policy

Policy & Procedure Statement

Subject: Policy Name
Effective Date:

Revision Date:

P&P Number: A.1

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

  1   2   3   4   5   6   7   8   9   ...   28

The database is protected by copyright © 2016
send message

    Main page