Range: New patient

Patient type: adult

Date of Activity: Monday, 9 November 2015, 9:00 AM
The Practical Experience Record Sheet is a true representation of my
I confirm
own involvement in the task described.
1. Clinical assesment procedure carried out: Age and medical history of patient:

Guidance Notes:
Students should state how the area was prepared, the equipment switched on, the safety and
PPE requirements considered, and how they assisted the clinician and the patient during the
procedure, including recognising abnormalities in the oral cavity where relevant.Students
should describe the patient on which the treatment was carried out.Students should state the
age of the patient and give details of their relevant medical history including the date of
completion.
PATIENT INFORMATION: Sex: Female Age: 29 year old - NHS patient; Medical/Social
History form up to date and signed; Health: Good. Patient concent: Gained, plan signed.

TREATMENT INFORMATION: Check up

CLINICAL AREA AND PREPARATION:

First thing in the morning I put on a clean uniform and footwear. Hand wash following the
correct sequence by NHS .

Make sure my hair is been tied back. I wear the correct P.P.E (Gloves, Mask,Goggles)

EQUIPMENT SWITCHED ON AND CHECKED:

- Lights
- Chair
- Dental unit & light
- Computer (Sign in with the dentist)
- Light cure
- Amalgamator
- X-ray machine
- Autoclaves (type B and N/S)
- R.O water machine
- Compressor
- Pouching machine
- Ultrasonic Machine
- R.O Machine
- Water Distiller (if necessary)
- Assistina Machine

- Dentist unit dental bottle is filled with purified water (RO machine) and flush water lines
for 2 minutes.

- Work surfaces wiped with alcohol free disinfectant and a microfibre cloth and put on
disposable covers.

- Surgery zoned into clean and dirty areas. The decontamination room  is adjoined.
- Put water and disinfectant solution into dirty instrument container and keep in dirty zone of
the surgery away from clean zone.

- All surfaces in decontamination room are wiped with disinfectant and wipes and microfibre
clothes.

- The ultrasonic machine is filled up with clean water and correct amount of ultrasonic
cleaner (30 ml of solution), then I switch the machine on for 7 minutes at 30 degrees
centigrade.

- Both autoclaves (type B and N/S) are clean and I wipe the inside and door seal; after
draining all the dirty water I fill the water tanks with purified water from distiller water
machine.

- The helix device and strip are placed in vacuum autoclave and press "B" cycle then start.

- The sterilizer class 6 strip is placed into "N" cycle non-vacuum autoclave and press 134
degrees cycle.

- Remove items from cold sterilizer bath, rinse and dry.

- I check day list already printed from the reception, and ensure there are enough exam and
treatment instruments/trays set up for the day.

- Check if all lab work has been collected from dentist box.

- Dentist and myself follow the 13 steps for hand washing done by NHS, placed new PPE
(gloves, mask and my safety glasses).

- I select on the computer patient's name,  leave open their records.

LIST OF INSTRUMENTS set up on dentist side:

- Mouth mirror
- Right angle probe
- Williams Probe
- 3 in 1 metal tip (air, water syringe)

LIST OF INSTRUMENTS/MATERIALS ON MY SIDE:

- Patient Bib, googles and bib holder
- Mouthwash in a disposable cup and tissues
- Fast suction tube
- Saliva ejector
- Spittoon funnel
- Bite - Wings holder
- 2 intra oral films

PROCEDURE:
- After medical and social question forms has been filled up and recorded on the system by
the receptionists, I bring  the patient into the room and provide a bib and safety glasses,
always making sure and asking if patient is comfortable to start the procedure.

- Dentist first welcomes the patient and present himself and myself as dental nurse. Ask if
patient has problems/pains recently. Ask about teeth-cleaning habits, diet, smoking and
drinking and give advice on the most appropriate ways to keep your mouth, teeth and gums
healthy.

- Is carried out a full examination of mouth, teeth and gums.

- Whilst dentist is checking each teeth for signs of decay, the gums and checking for signs of
oral cancer or other pathology diseases, I do the Palmer Charting (tooth charting) and the
Basic Periodontal Examination (BPE) on the computer, saving all the changes on the
Patient's file.

- Because is the first check up, dentist do a more thorough exam, including a thorough look
at patient's entire mouth, head and neck area; and always on first visit is taked x-rays (bite
wings usually).

- I pass the bite-wings holder with a x-ray film on to the dentist. Is placed inside of the mouth
for the patient to bite on. Same procedure into other side of the oral cavity.

-  X-rays already sprayed and developed by computer (digital radiography) and saved by
myself, dentist can look for decay (caries) or other oral health problems that cannot be seen
during the clinical exam. The radiographs also provide the best way for the dentist to see a
need for root canal treatment (RCT), or bone loss witch means gum diseases.

- In this case, Patient has a periodontal disease and Pt has aware of that. The patient
mentioned that for a long time does not visit a dentist for regular check up (3 years), but she
is been accompanied by a periodontist in the hospital, of course because of her perio/gum
problems.

- Explained what the causes are (e.g smoking, genetic, poor OH, systemic factors) and how
the disease progresses. Explained the type of treatment required and the maintenance
procedures.

- Dentist also gave option of seeing a hygienist on a private basis for a scale and stain
removal for a time specific session or having NHS treatment for any clinically necessary
scaling.

- Diet good, patient advised to maintain a low sugar diet and limit sugar in take to meals
where can. Fluoride mouthwash and toothpaste discussed and advised.

- I take patient to the reception to pay and to sign the treatment plan form and is given a
copy. Receptionists make an appointment for next visit to see the Hygienist.

2. Details of the clinical assessment process and the Dental Nurses role:

Guidance Notes:
Students should give details of the role they played during the procedure.
A Dental Nurse assists the Dentist in all aspects of patient care.

On a Check up appointment, dental nurses should:

- Get the appropriate instruments ready

- Take notes (Dental charting, Periodontal Probing) from dentists’ dictation for Patient's
personal records
- Develop and save the intra-oral x-rays taken

3. Reflective Account:

Guidance Notes:
Students should identify their strengths and weaknesses during the procedure and describe
any action they would take to address weaknesses in the future, if required.
STRENGTHS: Not rush. Everything was ready for dentist and patient on time.

WEAKNESSES: I get confuse on computer when I am charting.

13-12-2015:This is a new patient, pt mentioned that for a long time does not visit a dentist
for regular check up (3 years), but she is been accompanied by a periodontist in the hospital,
of course because of her perio/gum problems.

Preparation:
Student turned on all equipment required for the procedure: competent
Student donned appropriate PPE (gloves, mask, eye protection,
competent
appropriate clinical dress):
Student cleaned work surface using viricidal disinfectant or detergent
competent
solution:
Student flushed through all water lines: competent
Student applied disposable covers to required areas of the dental
competent
surgery e.g. light handles, control panel etc:
Student made all required patient records and radiographs available: competent
Identify the planned procedure and confirm with the clinician: competent
Student established zoning of clean and dirty areas within the
competent
working field:
Student prepared all instruments, materials and equipment required
competent
for the procedure in their order of use:

During Procedure:
Student provided the patient with a bib and safety glasses: competent
Student recorded accurate and contemporaneous patient history: competent
Student recorded accurate and contemporaneous oral health
competent
assessment:
Student recognised significant changes in the patients oral health
competent
status and took appropriate action (if applicable):
Student reassured the patient during the treatment: competent
Student provided clinician with illumination of the patients mouth: competent
After Procedure:
Student ensured that no sign of the treatment was left on the patients
face or clothing:
Student made arrangemnts for follow-up care as required:
Student ensured all dirty instruments were placed in teh correct
zoned area and are cleaned and sterilised, or set aside away from competent
treatment zones, ready for bulk cleaning and sterilisation:
Water is placed in the appropriate containers: competent
Spittoon and work surfaces are cleaned and disinfected. Tubing and
competent
light controls are recovered after cleaning has taken place:

Professionalism:
Student demonstrated professionalism in his/her duties and effective
competent
team working towards the delivery of safe, effective care:
Student demonstrated effective clinical decision making throughout
competent
the procedure:
Student managed themselves and the clinical environment in line
competent
with current standards and guidelines:
4. Witness Feedback

This Section should be completed by the GDC (or other) registrant who witnessed the
activity of the student and is assessing their competence. Constructive feedback will help the
student to develop their performance in the workplace.
Witness Assessment of Competency:
carolina  know  how  to  set  up  for  clinical  assessment  and  charting
I confirm that the performance of the student demonstrated
I confirm
competence as indicated in the table above
5. Tutor Feedback

This section should be completed by the GDC registrant who is assessing all sections of the
completed PER and is normally based at the Training Centre. Constructive feedback will
help the student to develop their performance in the workplace.
Tutor Feedback to Student:
24/11/15
Can you kindly inform me
1. length of time since previous vizit
2. previous tx received

10/12/15

Carolina - Please answer the questions above - do this in the reflective account

16/12/15

Many thanks
Tutor Judgement: satisfactory
Sampled by Internal
Moderator:
Meets NEBDN
requirements: