Hospital & Clinic Dental Practice Checklist

Facility name
Physical Location
Hospital hours
License No.
Date & Time
Audit Type: Renewal Concise/Follow up Adhoc
Name Title/License no. Name Title/License no.

HAAD Auditor HAAD Auditor

Name: Name:
Division : Division :
Auditor No.: Auditor No.:

International Patient Safety Goals

1. Improve the accuracy of patient identification

2. Improve the effectiveness of communication among care givers and care recipients
3. Improve the safety of using medications and medical devices
4. Reducing the risk of healthcare associated infections
5. Ensuring correct site, correct procedure, correct patient for all procedures
6. Accurately and completely reconcile medications across the continuum of care
7. Encourage patients active involvement in their own care as a patient safety strategy
8. Improve recognition and response to changes in a patient’s condition
9. Reducing risk of patient harm resulting from falls
10. Reduce the risk of hospital fires

P = PRIORITY PSG = PATIENT SAFETY GOALS

No. Ref Auditor Tasks Yes Partial No PSG Comments

1 HAAD Process in place to list the procedures that
standards(JCI) the dentist is allowed to do
(HS)#LDS 21
2 HAAD Policy Dentists are working according their 3,5
P professional license
3 HAAD Standards Patient confidentiality and privacy provided
(JCI) (HS) #CCC16
4 HAAD Policy Does the practice have an incident reporting
PPR/HCP/P002 policy and system in place For Patients?
4/07 Evidence of implementation and reporting
5 HAAD Are there Material Safety Data Sheets for all
Standards(JCI) chemical/Dental agents?
(HS) #FSE7

1
 6 HAAD Gloves, protective gowns and masks are used
Standards JCI for each patient
(HS) #HRC62
7 HAAD Is protective eyewear (face shield) worn by
Standards JCI staff
(HS) #HRC62
8 HAAD Is protective eyewear worn by patient?
Standards JCI Transparent or colored goggles
(HS) #HRC62
9 JCI Standards& Patient records system including Full personal 1,5, 8
P HAAD policy data, Chief complaint, medical history ,
30/60/010 dental history, Extra oral and Intraoral
examinations, dental chart, diagnosis,
treatment plan, Procedures in details, proper
follow-up signed/stamped by the dentist
10 HAAD Consent form ( signed by patient)
PPR/HCP/P000
3/09
11 HAAD Are there Dental practice guidelines/
standards(JCI) standards of care?
(HS)#PCQ12.2.c Are they relevant to the dentist’s specialty?
12 HAAD Patient education/information provided
Standards(JCI) regarding
(HS) #CCC26 condition/treatment/prognosis/follow-up
13 IAEA #115 Annual radiation safety inspection Survey for
X-Ray( for panoramic X-Ray) or FNAR licensed
and inspected
14 IAEA #115 X-ray lead apron available and used for
patients
Total Met Partially Met Not Met NA
Priori
ty
Non
Priori
ty

Hospital &Clinic Dental Practice HAAD Auditor

Name Name
Signature Signature
Date Date

Section Head Comments: …………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………….………………….…

Name: …………………………………………… Signature: ……………………………………. Date ……………….…………