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To ensure confidentiality and patient privacy and prevent loss, tampering and unauthorized access, the [Facility] Medical Records policies will be followed.


All patient information is confidential. Privacy Act and HIPAA training must be completed within 30 days of employment. Documentation of completed training will be placed in each employee’s personnel file. Information not covered under “Routine Uses” in the HIPAA rule can only be copied or removed from the dental file upon signed request from the patient. All information in a patient’s record is subject to HIPAA regulations.

Records are not to be left open in patient areas and charts are not to be left in public areas unattended. Schedules with names and procedures will not be left in areas visible to patients. Computer terminals will be situated in such a manner that information cannot be seen by non-staff. Computer terminals will not be left unattended while the employee is logged on (exception: employee uses computer “lock” function).

Data (Hard Copy Charts)

All patient visit data must be entered into the dental record by the end of the day of the patient visit. Charts must be monitored or kept in a secure location at all times. All charts must be filed by the end of each day with the exception of charts that are 'pulled' for future appointments. “Pulled” charts must be kept in a secure location. Patient visit data must be entered into the computer system no more than [## days] following the dental visit.
Training in Information Management

Training for dental documentation will be performed on site or arranged off site to fulfill requirements for the facility or the department. This training will be documented by [CE coordinator].



To describe staff requirements necessary to provide quality oral health services.


[Develop your own Staffing requirements]

The full time, permanent Dental Clinic staff will consist of two general dentists and five auxiliary personnel. The auxiliary personnel will be composed of one dental assistant supervisor, one dental hygienist, two chair side dental assistants, and one dental receptionist.

When available the dental hygienists will schedule patients through the dental receptionist. The hygienists will be responsible for starting new adult patients and seeing referrals from the dentists. New adult patients will be examined and treatment planned by the dentist assigned to exam duty. The hygienists will primarily work unassisted, but may be assigned an assistant depending upon staffing for the day.

When available, contract dental personnel shall be assigned to any free operatory. The contract dental personnel shall see specialty dental assignments referred to them by the full time dentists

Additional temporary providers, volunteers, and non permanent employees will be assigned into the clinic schedule to expand services when available.

Wednesday mornings no patients will be scheduled. Staff will use this time to attend meetings, stock dental units, complete required documents, or other administrative duties.

Duties of the Staff

The [Program Director] will develop, coordinate and evaluate the dental program. He/she will be responsible for the authorization, obligation and justification of funds for the contract dental care program. The [Program Director] will be responsible for career development activities of the dental staff under him/her. The [Program Director] will provide dental health services to the designated population according to clinical skills and privileges granted by the facility.

The [appropriate staff] is responsible for assigning duties to the dental staff. Staff assignment duties may be delegated to [appropriate staff].

The [appropriate staff] will act as Program Director in the absence of the Director.

[Appropriate staff] will serve as the Chairperson of the Dental Health Promotion / Disease Prevention committee. He/she will monitor ongoing HP/DP activities and make recommendations to the [Program Director] regarding clinical and community HP/DP activities.

A [appropriate staff] will be responsible for ordering all necessary supplies and maintaining inventory and budget control. A [appropriate staff] will serve as a member on the [appropriate committees or work groups].

Include other staff assigned duties as needed.



Training of employees is an indispensable portion of the function of the clinic. Training ensures that consistent quality procedures are provided in the dental clinic and community.


Training will be used to develop and improve abilities necessary to protect patients, provide high quality dental care, ensure effective programs and promote team cohesiveness to fulfill the mission of the department. Training may be provided through in-services at the facility, external continuing education (CE) courses, online CE courses, agency sponsored conference calls, or other distance learning mechanisms.
In Service

This training will be arranged through the [CE coordinator]. This training will be specific and will fulfill specific objectives such as orientation, safety, infection control, Occupational Safety and Health Administration (OSHA) requirements, Privacy Act/HIPAA, hazardous situations, record keeping, and other required topics. Outside presenters will be obtained to provide training for those topics that cannot be provided by this facility.
Continuing Education

Continuing education (CE) will be provided annually as resources permit. If resources become limited, prioritization will be done by the [Program Director]. Preference for external CE will be given to staff members who must obtain continuing education to maintain licensure and/or certification.

Employees are responsible for finding appropriate CE courses, determining if those CE courses fulfill State requirements, and requesting CE through the supervisor. Each licensed or certified dental staff member is responsible for completing adequate continuing education to maintain licensure or certification. Individual staff members are responsible for maintaining documentation of CE courses and reporting CE to the State licensing board as required.

Training needs will be determined by employee performance evaluations. Training requests must be submitted to and approved by [appropriate individual]. Each staff will identify long and short term training goals. Training priorities will be set by:

1. Improvement of skills necessary for job performance.

2. New techniques to be used in assigned clinical duties.

3. New clinical duties.

4. Acquiring skills that are identified as needs of the facility or department.


The [facility] may utilize students, trainees, and volunteers either in the provision of direct care or in direct support of health care services at the clinic.

The purpose of this policy is to outline the guidelines at [facility] for the provision of care for student externs, trainees, and volunteer health care providers.

Each student, trainee, or volunteer (herein referred to as volunteer) who provides direct care at the [facility] shall secure authorization from the [facility] Medical Director prior to providing any direct care on patients. [Insert types of documentation required] shall be furnished at least [time period required for document submission] prior to reporting for work.
All volunteers will comply with all [facility] policies and procedures.
All volunteers will have a position description that includes qualifications and major duties; other duties may be assigned as appropriate to the position. All volunteers will be given an orientation that includes but is not limited to:
Mission and goals of [facility];

HIPAA/Privacy Act;

Role and responsibilities of the student/trainee;

Employment policies governing volunteers;

Clinic eligibility and appointment policies;

Clinical policies pertinent to the volunteer’s scope of work;

Working hours including lunch and other breaks;

Required patient record documentation;

Grievance Policy;

Relationship of the various clinic departments;

Organizational Chain of Command;

Location of lunch area, restrooms, Director’s office, etc.;

Infection Control and Safety policies.
All volunteers will wear an identification badge while on site at [facility], and to return the identification badge [time when badge is to be returned] Example: at the end of the volunteer service, or upon final checkout.
Volunteers Providing Direct Patient Care Services
All volunteers providing direct care to patients will be introduced to the patient by the supervisor, or his/her designee, as a student/trainee/volunteer. The patient may refuse to be treated by the student/trainee/volunteer. The patient may accept to be treated by the student/trainee/volunteer by signing the Student Volunteer Form (attached). At all times when the student/trainee/volunteer is present, the supervisor is responsible for the provision of care, communication with the patient, and any follow-up care required.

If the student is in a formal externship agreement, a Collaboration Agreement or Affiliation Agreement must be signed and approved by the [facility] Clinic Director prior to the student’s arrival.

Attach Externship Agreement form(s)


Indian Health Service


Clinical services at IHS dental facilities are sometimes provided by dental or dental hygiene students visiting the clinic. These students are in the process of earning a degree from a dental or dental hygiene school.

I have been introduced to ________________________________________________________

(Name of student, plus title: “dental student” or “dental hygiene student”)

Visiting from ___________________________________________________________________

(Name of Professional Institution)
I understand this student will be providing clinical services for me today. I am aware this student has not yet earned a dental or dental hygiene license. I understand that all services provided by the student will be under the supervision of a licensed dentist or dental hygienist who is at this clinic while the student is treating me.
I understand it is my right to stop a procedure at any time if I do not feel comfortable with the student, and I may ask for a second opinion from the supervising licensed dentist or dental hygienist. I understand I have the right to be treated by a licensed dentist or dental hygienist. I understand that I may revoke or withdraw my consent to treatment by this student at any time.
I give my permission or consent to be treated by this dental or dental hygiene student. I agree that I have had the chance to ask any questions I have about these arrangements.

__________________________________________________ ____________________

(Signature of Patient) (Date)

__________________________________________________ ____________________

(Signature of Legal Guardian, If necessary) (Date)

__________________________________________________ ____________________

(Signature of Student) (Date)

__________________________________________________ ____________________

(Signature or Supervising Dentist or Dental Hygienist) (Date)
IHS-950 (9/04)

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