Section 2 - beginning of appointment

Standard 5
1. Has the patient been asked to confirm their

Other: please comment

2) Was the intended procedure advised to the patient at today's visit prior to them starting treatment?

3) Has the treating clinician matched the patients answers to the

4) The radiographs have been confirmed as correct?

5 a) Prior to referring for tests, such as radiographs, laboratory requests or other medical tests - has the clinician checked that:

All labels are labelled with a label consistent with the Titanuim information?

5 b) The request form has The correct patient information?

5 c) The request information been filled out correctly?

5 d) If generated from Titanium - is saved before closing to ensure all entered details are stored?


2) Was the Medication Management Plan used if the patient indicated on the General Health Questionaire if they were on any current medications?

Standard 8

1) On the General Health Questionnaire, has it been flagged for a Falls Risk Assessment form required to be completed
If yes, go to next question.
If no, go to standard 10

2 ) Is there evidence of a Pressure Injuries Risk Assessment form been completed?

Standard 10

1) On the General Health Questionnaire, has it been flagged for a Falls Risk Assessment form to be completed?
If yes, go to next question
If no, go to next section (3)

2) Is there evidence a Falls Assessment Screening Tool been completed?
If no, go to section 3

3) Is there evidence of a Falls Risk Assessment Tool (FRAT) completed?

Section 3 - during the appointment

Standard 4

1) Was any medication prescribed during appointment?
If no, please go to standard 6

2) Is there evidence to confirm the medication was checked before prescribing?
Tick all relevant methods undertaken

5) Did the patient receive discharge medication education?

Standard 6

1 Was handover witnessed during the appointment?
If no, select NA for all questions and go to section 4

2 Were any of the following clinical handover procedures applicable to this appointment?

3. What process was used to deliver handover?

If neither was selected, please explain why?

4 If a face to face discussion occurred with clinician ,was the information recorded in the patients record?
If yes, go to next question (4b)

4 a) If yes, was it recorded in

If other was selected, please explain where was Handover documented?

4 b) Was handover structured according to ISBAR principles
(I) identity or introduction. Establish the name and role of the person giving and relieving the information and the correct identity of the patient
(S) the clinical situation
(B) the background of the patient
(A) the clinical assessment (including observations)
(R) the recommendation or proposed plan including identification of risks .

5) Is there evidence the patient has been involved during the clinical handover process?

Section 4 - end of appointment

Standard 3

1) Soiled instruments are wiped immediately after use?

2) Instruments are checked ensuring they are free of debris before placing in cassettes or containers?

3) Spatulas are cleaned and wiped of dental material?

4) Materials such as wedges, cotton pellets and floss are removed from cassettes before transferring to dirty hold?

Chairside cleaning

Top surface

Behind headrest

Side Panels

Under arm rest

Bracket table

Under tray and rim

Side edge

Top surface

Switch Panel

Below switch panel

Bottom surface

Top surface

Hand piece bracket

Outer surface

Hand piece cradle and buttons

Hand piece tubing



Light cover and switch


Bench tops

Clean area

Contaminated area

Clerical area

Suction bracket

Outer surfaces


Hand piece cradle and buttons

Hand piece tubing


Inner bowl and upper ridge

Suction filter

X-rat unit




Trigger button

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.