ORAL HYGIENE INSTRUCTION PROFICIENCY PROCESS EVALUATION Name: Ste ul Fischon 2 Instructor: Patient — vate__7, 0 Competency: Provide patient counseling A= Acceptable Competency: Promote dental health l=Needs Improvement Competency: Assess own performance U=Unacceptable * Failure of starred item/critical errors results in automatic failure of proficiency |. Professionalism A T U Time management Professional behavior™ PASS FAIL Asepsis/infection contro (PASS) FAIL Il, Evaluates Patient Knowledge ‘Asks patient about current knowledge of dental disease/responds @ 7 0 appropriate Ill, Evaluate Patient General Condition Uses information from medical, dental and oral examination i 0 Uses information from dental and periodontal chart 1 0 IV Evaluates Current Periodontal Condition ‘Shows patient disease/health in patient's own mouth C2 1 0 Discloses plaque/completed plaque score 1 0 Uses plaque score to evaluate and determine home care procedures @ 4 0 V. Datermined Patient's Self Care Needs Allows patient to@emo Surrent brushing, flossing method in own mouth 2 0 Revises brushing/ffossing method as needediintro flossing if necessary | 2 0 Recommends brushing method and establishes routine with patient Ti 0 Recommends other home care needs and aids as necessary to patient_ | (2) 4 0 VI. Self-Assessment Criteria: >| ‘Student completes self assessment (PAS FAIL Discusses assessment with instructor™ ASS, FAIL = Gx 20 Instructor comments: Revised 2013