DHSV ANTT Dental

• Conducted on

  Date

• Prepared by

• Location
  Address

• there are no environmental risks

  Yes

  No

  N/A

Preparation

• instruments are opened at point of use

  Yes

  No

  N/A

• the bracket table is clean

  Yes

  No

  N/A

• hand hygiene is performed (5 moments)

  Yes

  No

  N/A

• instruments are gathered

  Yes

  No

  N/A

• everything is opened in an aseptic manner

  Yes

  No

  N/A

• blue wrap is present

  Yes

  No

  N/A

• non-touch technique is applied

  Yes

  No

  N/A

Personal Protective Equipment

• gown are worn (if high risk procedure)

  Yes

  No

  N/A

• mask are worn and fitted appropriately

  Yes

  No

  N/A

• glasses are worn and well fitted

  Yes

  No

  N/A

• 5 moments of hand hygiene is demonstrated

  Yes

  No

  N/A

• gloves are worn

  Yes

  No

  N/A

Procedure

• hand hygiene (5 M/Gloves)

  Yes

  No

  N/A

• non-touch technique is demonstrated

  Yes

  No

  N/A

• needle are disposed appropriately after use

  Yes

  No

  N/A

• key parts are separated and protected on the bracket table

  Yes

  No

  N/A

• bracket table is uncluttered

  Yes

  No

  N/A

Type of field is managed correctly

• general aseptic field is managed correctly

  Yes

  No

  N/A

• critical aseptic field is managed correctly

  Yes

  No

  N/A

• surgical aseptic field is managed correctly (DSU)

  Yes

  No

  N/A

• Point of use wiping is managed correctly

  Yes

  No

  N/A

• sharps are disposed appropriately

  Yes

  No

  N/A

• waste is segregated and disposed appropriately

  Yes

  No

  N/A