Care Plan Evaluation Form

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GRADING CRITERIA: ,/ ,.A/
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A score of l will be given if no significant errors are identified. |)
A score of %will be given if 1-3 significant errors are identified.
A score of 0 will be given if required information is missing of deemed inaccurate by the instructor.
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I 1. Patient information is present.
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I Z. Medical Historyfindings are present.

, Medical History risks are identified.

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_l+. Social and Dentat history findings are present.

'b, Socialand Dentalhistory risks are identified.

,) a. Dental Examinations findings are present.
6, DentalExamination risks are present.

l-t PIaque score catculated correctly.

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1 9. Bleeding score calculated correctly.

-l- to. Periodontat information assessed correctly.

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__l_L7. Dental hygiene diagnosis problems stated correctly.
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lLrr. Dental hygiene diagnosis risk factors or etiology stated.

]- 13. Planned lntervention education stated clearly for each clinical finding.

14. Planned intervention oral hygiene is appropriate for each clinical finding.

15. LTG 1 stated clearly.

II 15. STG 3 goals stated appropriate for LTG 1

I ,r. LTG 2 stated crearry.

-l-rt. STG 3 goals stated appropriate for LTG 2

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LTG 3 stated ctearty.

3 goals stated appropriate for

'brrSTG LTG 3.