Care Plan Evaluation Form

Student __________________________________ Date ___________________

Patient Name _____________________________ Instructor ____________________
Grading Criteria:
A score of 1 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 will be given if re!uired information is missing of deemed inaccurate b" t#e instructor.
____ 1. All identif"ing information is $resent.
____ %. &ital signs are listed and evaluated.
____ 3. Pla!ue score and 'leeding score are correctl" determined( evaluated and noted.
____ ). Amount of $la!ue and areas of accumulation are described.
____ *. 'iofilm retentive features and $redis$osing factors for $la!ue retention are listed.
____ +. ,urrent -ral Self ,are .et#ods are described.
____ /. .edical conditions are listed and $ossible treatment modifications are described.
____ 0. Allergies are listed.
____ 1. .edications are listed wit# dental im$lications.
____1. Patient2s tobacco use( fre!uenc"( and t"$e are noted.
____11. Patient2s last dental visit and treatment rendered are noted.
____1%. ,#ief com$laint of t#e $atient is noted and in t#e $atient2s own words.
____ 13. Patient2s 3earning 3evel and clinician2s rationale are stated.
3earning 3evel is recorded on Progress notes at ever" a$$ointment.
____ 1). All $ositive findings are listed on t#e ,#art of Positive 4indings.
____ 1*. Patient2s dental $roblems are listed and correctl" $rioriti5ed on t#e ,#art of Patient Needs.
____ 1+. 6tiologies for eac# $roblem are correctl" stated on t#e ,#art of Patient Needs.
____ 1/. Positive findings t#at correlate wit# t#e $roblem are noted on t#e ,#art of Patient Needs.
___ 10. Patient 6ducation to$ics are listed and are a$$ro$riate for eac# $roblem.
___ 11. 7reatment o$tions and $reventive t#era$ies #ave been indicated for eac# $roblem.
___ %. 3ong term goal for treatment are stated and $atient $artici$ation is evident.
___ %1. S#ort term goals t#at will facilitate reac#ing t#e long term goals are stated and a$$ro$riate.
___ %%. 7#e clinician2s assessment of t#e $ossibilit" of goal attainment is stated and e8$lained.
___ %3. Patient education sessions are outlined and information to be $resented is clear.
___ %). .et#od of $resentation and t#e use of visual aids are a$$ro$riate for t#e to$ic.

___ %*. Patient $artici$ation is $ro$erl" $lanned into t#e $atient education sessions.
___ %+. Individual dental #"giene a$$ointments are a$$ro$riatel" $lanned wit# a realistic time allocated
for eac# $rocedure to be $erformed.
___ %/. 9ecall sc#edule is a$$ro$riate for t#e $atient.
___ %0. 9eferrals are noted( if indicated.
___ %1. ,are $lan is submitted to t#e assigned instructor no later t#an one wee: after com$letion of t#e
data collection.
POINTS = GRADE
POSSIBLE POINTS !"#
CLINIC I $%% & '% = S
(" ) % = *