Checklists

CONSULTATION AREA SUPPLIES

Checklist #1

Please have the receptionist prepare the consultation area prior to my arrival to include the following items:

• Patient should have already received the Pre-Operative Instructions (1 of 8).
• Surgical treatment plan and associated fees should be attached to outside of patient's chart.
• Have patient complete an updated Medical History Review Form (3 of 8).
• X-ray attached to outside of chart:
  • Panoramic is mandatory for all 3rd molar extractions.
  • Periapicals are acceptable for all other extractions.
  • All X-rays must be less than one (1) year old.
• Oral surgery forms--inside or attached to the chart:
  • Acknowledgment of Receipt of Privacy Practices (2 of 8)
  • Disclosure & Consent (4 of 8)
  • Supplemental Disclosure & Consent (5 of 8)
  • Post-Operative Instructions (6 of 8)
  • Patient Treatment Record (7 of 8)
  • Anesthesia Record (8 of 8)
• Post-operative gauze package (preferably in an autoclave bag)

If patient is having IV sedation:

• Ask patient to use restroom, if necessary, prior to my arrival.
• Remind patient not to eat or drink at least six (6) hours prior to appointment.
• Remind patient that they must have an escort to accompany them to the office, to remain with them throughout the procedure, and to take them home following the procedure.

Thank you.

OPERATORY (SURGICAL) SUPPLIES

Checklist #2

Please have your assistant prepare the surgical operatory prior to my arrival, to include the following items. NOTE: Some offices find it helpful to fill a box with the surgical supplies listed below in order to streamline preparation of the surgical operatory.

• Local anesthetic:
  • 2% Lidocaine w/ 1:100,000 epi—1 package
  • 0.5% Marcaine or Vivicaine w/ 1:200,000 epi—4 carp (per patient)
• Dry gauze 4 x 4
• Dental floss
• Alcohol gauze
• #15 scalpel blade x 2 (per patient)
• 3° or 4° gut sutures (3° chromic gut preferred)
• Four (4) monoject #412 syringes (per patient)
• Patient bib x 6 (per patient)
• Two (2) 27 gauge long, yellow
• Local anesthesia needles (per patient)
• Medium gloves
• Nitrous unit (w/ tanks turned on and mask in place)
• Large sterilization bags (9” x 15”)—three (3) per patient
• Three (3) Dixie (or plastic) cups
• Dry socket paste

Thank you.