Download ucsf school of dentistry laboratory and clinics policies

University of California, San Francisco
School of Dentistry
UCSF SCHOOL OF DENTISTRY
LABORATORY AND CLINICS
POLICIES AND PROCEDURES MANUAL
Foreword
This manual was developed by Clinic Administration to provide you with
information concerning the operation of the School's clinical facilities and
clinic laboratories. We hope the information contained in the manual will
assist in making your clinical experiences proceed smoothly. As changes
in practice or policy occur, we will distribute changes.
If you have any questions or need assistance in any way as you work in the
Clinic facilities, please do not hesitate to contact the clinic administrative
personnel. An organizational chart describing the Clinic Administrative
Directors and their areas of responsibility can be found in Table I.
Table of Contents
Section 1
I.
II.
III.
IV.
V.
Section 2
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
Section 3
Parnassus Clinics General Information
Building Hours for Public Access
Hours of Operation for Patient Care
Laboratory Hours
Building Access Other Than During Public Access Hours
General Clinic Policies
Professional Responsibilities to the School of Dentistry
Statement of Educational Philosophy
Professional Liability Coverage
Code of Conduct - Student Honor Code
Planned Absence for Off-Campus Activities
Professional Appearance Guidelines
Student Absence Policy
Unplanned Absence
Course Based Clinical Suspension
Professional Responsibilities to the University/Ethical Principles
Professional Responsibilities to the University/Professional
Communities
Professional Responsibilities to Patients
Patient Care Responsibilities
I.
Patient Appointments
II.
Patient Registration
III.
Emergency Services Clinic
IV.
After-Hours Emergency Services
V.
New Patient Visit Protocol (NPV)
VI.
Patient Assignment
VII. Student Responsibilities To Assigned Patients
VIII. Patient Distribution
IX.
Intake Policy for Family and Friends
X.
Comprehensive Oral Exam (COE)
XI.
Periodic Oral Exam (POE)
XII. Financial Polices and Procedures
XIII. Patient Management Responsibilities
XIV. Patient Status
XV. Transfer of Patients Between Predoctoral Clinics
XVI. Referral of Patients to Oral Medicine Clinic
XVII. Student – Patient Linkage System
XVIII. Student, Faculty and Patient Eyewear Policy
XIX. Proper Instrument Arrangement and Placement in the Operatory
XX. Nitrous Oxide/Oxygen Portable Unit Use – Policy and Procedures
Section 4
Dental Patient Bill of Rights and Responsibilities
Section 5
I.
II.
III.
IV.
V.
Patient Concerns and Grievances
Purpose
Policies
Procedures
Review, Analysis, and Referral
Complaints Originating in Predoc Clinic or Buchanan Dental Center
I.
II.
III.
IV.
Patient Records
Record Room
Commonly Asked Questions
Patient Chart Drop off at 5:00pm
Release of Health Information
Section 6
Section 7
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
XII.
XIII.
XIV.
XV.
XVI.
Section 8
I.
II.
III.
IV.
V.
VI.
Financial Policies
Introduction for Predoctoral Students
Production Equivalent Amounts
Charge Entry & Missing Charges Report
Unapproved Treatment
Remove Unapproved Treatment
Accounts Receivable
A/R Documentation
Student Appointment Entry
Electronic Claim Process
Allocations from Another Clinic
Unallocated Payment Allocation/Reporting
Process for Unallocated Review
Adjustment Codes
Refunds
Reconciliation Activities
Staff Training
Definitions
Attachment I
Attachment II
Attachment III
Attachment IV
Attachment V
Emergency Procedures
Medical Emergencies
Emergency Cart Components/Supplies
Cardiopulmonary Resuscitation (CPR) Requirement
Injuries and Accidents
Protocol for Obtaining Material Safety Data Sheets
Fire or Earthquake Procedures
VII.
VIII.
Section 9
UCSF Dental Center Building Emergency Numbers
UCSF Websites – For Emergency Information
I.
II.
III.
IV.
V.
VI.
VII.
Health and Safety Policies
Bloodborne Pathogens Exposure Control Plan
Hazard Communication Program
Injury and Illness Prevention Program
Tuberculosis Exposure Control Plan
Ionizing Radiation Policy
Health Care Personnel Infected with Bloodborne Pathogens
OSHA Needle Safety Requirements
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
Infection Control Protocol
Introduction to Infection Control Concepts
Clinic Policy on the Use of Hypoallergenic Gloves
Infection Control Protocols for Clinical Procedures
Protocol for Clinic Materials and Equipment
Infection Control for Laboratory Procedures
Infection Control Protocols for Radiographic Procedures
Sterilization and Dispensary Procedures
Protocol for Needlestick Exposures
Other Infection Control Procedures
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
Radiation Policies and Safety Protocols
Location
Hours
Initial Evaluation
Prescription
Time Allotment
Facilities
Archives
Film and Technique
Endodontic Films
Film Release and Records
Radiographic Exposure Log
Section 10
Section 11
Section 12
I.
II.
III.
Dental Equipment/Instrument Policies and Procedures
Student Locker Assignment, Storage, and Security Policy
Missing/Lost Instruments and Equipment Replacement Policy and
Procedures
Magnification Loupes Policy
Section 13
I.
II.
III.
Section 14
I.
Section 15
Student Stores and Sterilization
Student Store – General Information
Student Store Services
Central Sterilization Room (CSR) Services
Laboratory Policies and Procedures
Predoctoral Clinic Lab Policies and Procedures for Removable
Prosthodontic and Restorative Lab Work
I.
Dispensary
Second Floor Predoctoral Dispensary
I.
II.
Operatory and Lab Maintenance Procedures
General Policies
Dental Equipment Maintenance and Repair
Section 16
Section 17
I.
II.
State Board Examination Information
Protocol for Dental Licensure Exam Patient Evening Screening
Protocol for State Board Patient Screening in the Comprehensive
Care Clinics
Section 18
Summer Session Only/Limited Status Student
Section 19
UCSF Policy on Sexual Harassment
TABLES
I.
II.
Organizational Chart
Patient Services Directory
SECTION 1 – PARNASSUS CLINICS GENERAL INFORMATION
I. Building Hours For Public Access
A. Public access to the Dental Clinics Building is 6:00 a.m. – 6:00 p.m.
Monday- Friday. There is no public access to the Dental Clinics Building
on Saturday and Sunday, except for special activities (e.g., Dental
Licensure Examinations, Continuing Education courses). The Dental
Clinics Building is closed on University holidays.
II. Hours Of Operation For Patient Care
A. Parnassus daytime clinic hours are 8:30 a.m. to 12:00 p.m. and 1:30 p.m.
to 5:00 p.m. Patient appointments begin at 8:30 a.m.
B. Students may not treat patients during non-clinic hours. Faculty
supervision is required for all patient care procedures.
C. Students should plan for adequate time at the close of each patient visit
to dismiss patients, complete records, obtain signatures, clean the
cubicle, and return items to the dispensary, including instruments and
handpieces for sterilization.
D. Attending faculty are responsible for remaining with the student and
patient until treatment is completed and the patient is in an upright chair
position.
E. Registered patients of the clinic have 24 hour access to emergency
services (See Section 3B).
III. Laboratory Hours
A. The Fleming lab on the 4th floor is open and available 6:00 am – 6:00pm
Monday – Friday, except during scheduled lab classes, University
Holidays, Continuing Education Courses and licensure examinations.
Closure for the above events will be posted prior to the event (normal lab
classes excepted).
SECTION 1 – PARNASSUS CLINICS GENERAL INFORMATION
B. During other times, students may gain access to the 4th Floor Lab by
using their UCID card. The electronic card readers on the lab doors will
grant access to individuals with valid UCID cards. Card access is granted
by SOD Facilities Manager. Card access will not work during the hours
of 12am-6am.
C. If your current UCID will not open the lab door, activation must be
requested from the SOD Facilities Manager. Please allow two days for
your card to be activated.
D. Monday to Friday Janitorial services will commence at 10:00pm. At that
time, all students must exit the lab so that the janitors can clean the lab.
Lab doors are electronically locked at 10:00pm.
E. The laboratory on the 2nd floor will be accessible to students Monday –
Friday from 7:30 a.m. – 10:00 p.m., except on University holidays and
during Dental Licensure Examinations.
IV. Building Access Other Than During Public Access Hours
A. All personnel (faculty, staff & students) should carry their UC ID cards
with them at all times.
B. Access to the building is limited to faculty, authorized staff and registered
students. Friends and family members are not to be present in the clinics
outside of clinic hours. Entry to the Parnassus Dental Clinics Building
after hours is by UC ID card only. Campus Police will respond to calls for
assistance, dial 9-911 for emergencies and 6-1414 for non-emergencies.
C. Security personnel may request individuals in the building to present their
UC ID cards.
V. General Clinic Policies
A. Emergency call buttons connected directly to the campus police
department are located in laboratories and restrooms.
SECTION 1 – PARNASSUS CLINICS GENERAL INFORMATION
B. Keys – UC ID card and keys for wooden lockers and cubicles are
obtained from Juan Zaldana (Student Store, Room D1046). There will be
a fee to replace lost or stolen UC ID cards. Replacement cards can be
purchased at the MU G Level UCPD WeID.
C. Student Lounge - A student lounge is located in D-2209. Students are
responsible for keeping this facility clean and organized. Notices and
flyers concerning student sponsored activities should be posted on the
bulletin board in this area and not in the clinics, stairwells, or elevators.
D. Lost and Found - Inquiries about lost items should be directed to the first
floor information and registration desk. Items found should be turned in to
the first floor information and registration desk for safe keeping and
return. Inquiries concerning lost instruments or equipment should be
directed to the Facilities Manager – Room D1044.
E. Smoking is not permitted in any area of the Dental Center.
F. Eating or drinking is not allowed in the clinics or laboratories
G. Parking - there is limited parking in the Parnassus campus area. The
information and registration desk on the first floor has brochures
describing parking, including parking for the handicapped. This
information can also be found at
http://www.campuslifeservices.ucsf.edu/transportation/parking.The Dental
Center is accessible by public transportation and its use by patients and
visitors should be encouraged.
H. Telephone Messages for Students - A message may be recorded on the
student’s voicemail message center. Students should check voicemail
box on a daily basis.
I. Paging System - A paging system located at the information and
registration desk on each floor, will be used to make appropriate
announcements and to page students, faculty and staff as warranted.
Paging is kept to a minimum. Requests for paging will not be accepted
SECTION 1 – PARNASSUS CLINICS GENERAL INFORMATION
from students or patients, except for patient care issues (e.g., paging a
faculty member to an operatory).
J. Mail Boxes - Mail boxes for clinic administrative or academic information
and other mail for students are located at the rear of the second floor
clinics (next to the student support lab). Academic materials will be
distributed by the departments and the Office for Student Academic
Affairs.
K. Telephone Calls - Telephones are available for calls to patients (within
the San Francisco Bay Area) in each clinic, student labs and student
lounge. Personal calls are prohibited. Inappropriate use of telephones
may result in disciplinary action.
L. Name Tags - Must be worn in clinics at all times. When participating in
clinical activities that require the use of a gown, students must wear a
name tag provided by Clinic Administration.
M. Unauthorized Personnel in Clinics - During clinic hours, the presence of
individuals other than patients, faculty, staff or student providers in clinics
or cubicles is prohibited. Individuals disruptive to patient care will be
required to leave the clinic area. Patients should be informed that child
care is unavailable at the clinics.
N. Use of predoctoral clinical facilities is for treatment of registered patients
of UCSF School of Dentistry. Friends or family members may not assist in
patient care activities.
O. Patients are not permitted in the clinical laboratories.
SECTION 2 – PROFESSIONAL RESPONSIBILITIES TO THE SCHOOL OF
DENTISTRY
I.
STATEMENT OF EDUCATIONAL PHILOSOPHY
A. We, the faculty, students, and staff of the UCSF School of Dentistry,
are committed to fostering an environment of mutual trust and respect.
We believe this goal requires clear communication, compassion for
others, and enthusiasm for the dental profession. To this end, we
accept personal responsibility for our interactions with patients and
colleagues and we encourage one another through constructive
guidance. This team philosophy will be the foundation of all our
endeavors, even in challenging times. In this way we will continue to
achieve academic and clinical excellence, create lifelong professional
partnerships and provide lasting contributions to the greater
community.
II.
PROFFESIONAL LIABILITY COVERAGE
A. All students who are registered at the University of California are
covered by the UC liability self-insurance program when treating
currently registered patients under the supervision of a faculty
member. If no faculty clinician is present during such patient
treatment by the student, the student is not protected by liability
coverage. The student is personally liable for problems arising from
any unauthorized patient care. Refer to Code of Conduct in the
Student Handbook.
B. Faculty are covered by the University of California professional liability
insurance when they are providing or supervising patient care.
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SECTION 2 – PROFESSIONAL RESPONSIBILITIES TO THE SCHOOL OF
DENTISTRY
C. Any questions or potential situations regarding professional liability
should be discussed with the Clinic Director. Any patient grievances
should be handled in the same manner.
III.
CODE OF CONDUCT- STUDENT HONOR CODE
A. Honor Code of the UCSF School of Dentistry
1. Introduction
a. All students in the University of California system are held to
standards of conduct described in University of California
Policies Applying to Campus Activities, Organizations and
Students (Revised 8/15/94). http://osl.ucsf.edu/pol/index.html
b. In addition, students in the UCSF School of Dentistry are held
to high standards of professionalism, recognizing the special
responsibilities inherent in patient care and clinical activities.
B. Professional Responsibilities, Ethical Principles, and Unacceptable
Student Conduct
1. This statement of professional responsibilities and ethical
principles was written by and for the students in the School of
Dentistry, UCSF. Its intent is to promote the highest standards of
scholarship and patient care. The statements of ethical principles
express student consensus about basic precepts of behavior as
scholars, as care providers, as members of an educational
community, and as members of the University and the dental
profession. The examples of unacceptable behavior, while not
comprehensive or all-inclusive, express student consensus about
Revised: Apr-11
SECTION 2 – PROFESSIONAL RESPONSIBILITIES TO THE SCHOOL OF
DENTISTRY
minimal standards of behavior and give fair notice to all that
departures from these minimal standards may incur disciplinary
proceedings.
C. Scholarship
1. Ethical Principles
a. As scholars, the students’ role is one of pride, determination,
and integrity. In the classroom, we are responsible and
respectful, encouraging learning by all. We understand that
failure to prepare in a thorough, timely manner reduces the
potential of our educational experience. We believe that the
student who cheats loses more than potential; that student
also cheats the public, creates publicity detrimental to the
stature of UCSF, and invites future malpractice suits. For
these reasons, we, as scholars, will not tolerate educational
dishonesty. We place the value of our education paramount.
D. Types of Unacceptable Behavior
1. Misrepresenting the work of others as your own, such as cheating,
plagiarism, or failure to credit the contributions made by others
2. Repeated inexcusable absences from classes or clinical activities
a. Repeated failure to adhere to assignment or examination
schedules
b. Loud or disruptive entrances when tardy.
E. Professional Responsibilities to Patients
1. Ethical Principles
Revised: Apr-11
SECTION 2 – PROFESSIONAL RESPONSIBILITIES TO THE SCHOOL OF
DENTISTRY
a. As health care providers, the students’ primary obligation of
service to patients includes delivery of competent, timely, and
supervised care within the bounds of clinical circumstances
presented by the patients and the dental school. Our conduct
regarding scheduling, quality and sequence of treatment,
faculty signatures, finances, and control of infectious diseases
will follow the policies of the School of Dentistry, the principles
of ethics and code of conduct of the American Dental
Association, and the Dental Practice Act of the State of
California. We recognize our own limitations and seek the
advice of those whose knowledge and experience exceed our
own. In doing so, we not only improve the quality of care for our
patients, but also expand our own knowledge. We understand
that our education does not end with graduation but continues
throughout our professional lives. The quality of care for our
patients is our primary concern.
2. Types of Unacceptable Behavior
a. Misuse of any documents related to student academic progress or
to patient care, such as failure to verify adequate supervision by
obtaining proper signatures, failure to maintain confidentiality of
patient records, removal of dental records from the clinic facilities,
or failure to promptly return records to central record storage areas
b. Refusal to comply with clinic protocol regarding patient appointment
or financial arrangements
c. Failure to comply with policies for controlling infectious diseases
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SECTION 2 – PROFESSIONAL RESPONSIBILITIES TO THE SCHOOL OF
DENTISTRY
d. Failure to obtain adequate faculty supervision for all phases of
patient care
e. Refusal to treat any assigned patient because of race, color, creed,
gender, national origin, sexual preference, economic status, or
handicap
f. Failure to make arrangements for emergency care of assigned
patients and to act as the primary source of emergency care during
clinic sessions, except when excused by conflicting activities such
as rotations or off-campus clinical assignments
g. Failure to seek assistance when the welfare of the patient would be
safeguarded or advanced by others with special skills, knowledge,
or experience
h. Failure to report to the appropriate agency instances of gross and
continual faulty treatment by other practitioners or students and to
exercise care that such criticism is justified.
F. The University
1. Ethical Principles
a. As members of the educational community, we understand and
support the goals of our peers, of the faculty, and of the staff to
participate fully in the learning experience. We share our failures
and successes for the gain of all in the spirit of collegiality. We
listen to the opinions of others with respect. We strive to reach the
highest levels of scholarly and technical excellence, and we
willingly assist others in similar efforts. In sum, as students, we
treat all members of the University community as we ourselves
would like to be treated.
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SECTION 2 – PROFESSIONAL RESPONSIBILITIES TO THE SCHOOL OF
DENTISTRY
2. Types of Unacceptable Behavior
a. Failure to recognize the authority of members of the faculty or of
University officials, such as campus security officers
b. Failure to present proof of current registration (identity card) upon
request by University officials when using University facilities,
equipment, or resources
c. Use of patient care areas and their fixtures without faculty
supervision
d. Failure to turn in any found property to the appropriate Lost and
Found Office.
G. University and Professional Communities
1. Ethical Principles
a. As members of the University and the dental profession, we
understand that our words and actions in daily life may be
attributed to all members of the University and the professional
communities. We therefore conduct ourselves to maintain the
esteem of the University of California and the dental profession.
2. Types of Unacceptable Behavior
a. Indiscriminate use of obscene language or gestures in the
University’s facilities
b. Failure to maintain a superior standard of personal hygiene and
of cleanliness and neatness of one’s self and one’s
surroundings whenever contact with patients is likely, such as
failing to comply with policies regarding clinic attire or failing to
thoroughly clean up one’s clinical cubicle after each use
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SECTION 2 – PROFESSIONAL RESPONSIBILITIES TO THE SCHOOL OF
DENTISTRY
c. Keeping a University fee paid by a patient for any dental service
or procedure
d. Requesting or encouraging in any manner gifts from patients
e. Misuse of UCSF affiliation, such as attributing personal opinions
to the School or the University
f. Misrepresenting professional status, such as using unearned
professional titles while still a student
g. Unethical behavior when taking any licensing examination
IV.
PLANNED ABSENCE FOR OFF-CAMPUS ACTIVITIES
A. Planned absences may include medical appointments, jury duty, court
appearances, family emergencies, etc.
B. Non-UCSF School of Dentistry Externship Activities
1. All student related externship activities (those not included in the
formal educational program) must be conducted on the student’s
personal time and have prior approval from the Associate Dean for
Education and Student Affairs and Clinic Directors. These are elective
activities and not covered by UC professional liability. Students are
responsible for obtaining and paying for their professional liability
insurance.
C. Clinical Absence
1. Complete a Planned Absence Form, have it signed by the Associate
Dean for Education and Student Affairs, Clinic Directors and
applicable course director(s) then return it to Educational Services in
room D- 4010, as soon as possible, or at least one week prior to your
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SECTION 2 – PROFESSIONAL RESPONSIBILITIES TO THE SCHOOL OF
DENTISTRY
planned absence. You may obtain a Planned Absence Form from
Educational Services, Clinic Administrative Services or on CLE
(Appendix 2.IV.C.1). For an absence beyond one week, the form will
need to be approved by the Associate Dean for Education and
Student Affairs. Absence longer than one week may require a “fitness
to return to school” report from your healthcare practitioner. Forms
will be filed in your student record in Educational Services for
reference.
D. Non-Clinical Absence
1. Planned Absence Forms are available in Educational Services and
from the Clinic Directors. Have your course director(s) sign the
form and return it to Educational Services. For an absence beyond
one week, the form will need to be approved by the Associate
Dean for Education and Student Affairs. Absences longer than one
week may require a “fitness to return to school” report from your
healthcare practitioner. Forms will be filed in your student record in
Educational Services for reference.
V.
PROFFESSIONAL APPAREANCE GUIDELINES
A. Types of Unacceptable Behavior: Failure to maintain a superior standard
of personal hygiene and of cleanliness and neatness of one’s self and
one’s surroundings whenever contact with patients is likely, such as
failing to comply with policies regarding clinic attire or failing to thoroughly
clean up one’s clinical cubicle after each use
VI.
STUDENT ABSENCE POLICY
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SECTION 2 – PROFESSIONAL RESPONSIBILITIES TO THE SCHOOL OF
DENTISTRY
A. Absence Protocol
1. Absence from a class requires approval from a course director.
Absence from the clinic requires approval of a clinic director. Student
notification of absence does not constitute an excused absence. It is
the student’s responsibility to contact the course directors regarding
makeup work for absences. Refer to the course outlines for policies on
attendance and makeup work for the specific courses you are taking.
If you will be absent from an examination it is critical that you contact
the appropriate course director directly before the examination is
scheduled to begin. (Students who are “no-shows” for an examination
without an adequate reason may receive a failing grade.) If your
instructor(s) requires you to document your absence, request an
Absence Record, from Educational Services in Room D 4010 once
you return to school. The document will verify your fitness to return to
clinic and/or class. The procedures are outlined to provide direction for
students who must be absent from a class or clinic.
VII.
UNPLANNED ABSENCE
A. Unplanned Absence - Clinical Absence
1. Call your scheduled patients early, ASAP, to cancel their appointment.
If you are scheduled to treat patients at the Buchanan Dental Center,
dial 476-4930 between 7:30am and 8am. Speak directly with someone
and let them know that you are unable to treat your patients that day.
Do not leave a voice mail message. You must call every day that you
are out sick.
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SECTION 2 – PROFESSIONAL RESPONSIBILITIES TO THE SCHOOL OF
DENTISTRY
2. Call the Clinic Administrative Services Office (476-1778) to inform
them of your absence, that you have contacted your patients to cancel
or that you need Clinical Services assistance in contacting your
patients. The Clinic Administrative Services Office will inform
additional faculty and staff of your absence. If the Clinic Administrative
Services Office is unavailable, call Educational Services (476-1101)
and ask to speak to Student Services to report your absence. (If
Student Services staff is not in, ask to speak to Student Records
staff). The Educational Services Office will document the absence and
will inform additional faculty and staff of your absence. When
appropriate, visit Student Health Services or a health care provider for
treatment of illness.
B. Non-Clinical Absence
1. Call Educational Services (476-1101) and ask to speak to Student
Services to report your absence. (If Student Services staff is not in,
ask to speak to Student Records staff). The Educational Services
Office will document the absence and contact course directors by email.
VIII.
COURSE-BASED CLINICAL SUSPENSION
A. Patient welfare is the most important part of each clinical course. In these
courses, students’ knowledge, application of skills, and behavior must be
evaluated by the faculty throughout the course to insure that patient welfare
is protected. Such student evaluation cannot wait until the end of a quarter,
as it does in didactic or laboratory courses. In the event that a student’s lack
of knowledge or skill or inappropriate behavior places a patient’s welfare at
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SECTION 2 – PROFESSIONAL RESPONSIBILITIES TO THE SCHOOL OF
DENTISTRY
risk, the course director, in consultation with appropriate faculty members,
will take action to protect the patient and provide remedial instruction for the
student.
B. The course directors’ actions can range from consulting with the student to
suspending him/her from clinical activities in that course for a defined period
of time. Initial suspensions will usually be for a period of one week, additional
or longer suspensions can be imposed as necessary. During the period of
suspension, there will be a meeting between the student, Course Director,
and Associate Dean for Education and Student Affairs, at which a plan for
the student’s remediation and clinical reinstatement will be developed.
Failure to remediate problems that lead to suspension can be grounds for
failing the course.
C. Examples of circumstances in which ongoing evaluation of student clinical
performance may lead to suspension:
1. The student lacks basic knowledge to perform or apply specific clinical
procedures.
2. The student lacks the necessary psychomotor skills for a given clinical
procedure.
3. The student exhibits poor communication skills which lead to
misunderstandings with patients and/or faculty, or which interfere with
safe and effective treatment of patients.
4. The student does not comply with appropriate requests made by
attending faculty.
5. The student exhibits a lack of respect or compassion for a patient.
6. The student willfully neglects clinic or course policy.
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SECTION 2 – PROFESSIONAL RESPONSIBILITIES TO THE SCHOOL OF
DENTISTRY
IX.
PROFESSIONAL RESPONSIBILITIES TO THE UNIVERSITY/ETHICAL
PRINCIPLES
A. Ethical Principles
1. As members of the educational community, we understand and
support the goals of our peers, of the faculty, and of the staff to
participate fully in the learning experience. We share our failures and
successes for the gain of all in the spirit of collegiality. We listen to the
opinions of others with respect. We strive to reach the highest levels
of scholarly and technical excellence, and we willingly assist others in
similar efforts. In sum, as students, we treat all members of the
University community as we ourselves would like to be treated.
B. Types of Unacceptable Behavior
1. Failure to recognize the authority of members of the faculty or of
University officials, such as campus security officers
2. Failure to present proof of current registration (identity card) upon
request by University officials when using University facilities,
equipment, or resources
3. Use of patient care areas and their fixtures without faculty supervision
4. Failure to turn in any found property to the appropriate Lost and Found
Office.
X.
PROFESSIONAL RESPONSIBILITIES TO THE
UNIVERSITY/PROFESSIONAL COMMUNITIES
A. Ethical Principles
1. As members of the University and the dental profession, we
understand that our words and actions in daily life may be attributed to
Revised: Apr-11
SECTION 2 – PROFESSIONAL RESPONSIBILITIES TO THE SCHOOL OF
DENTISTRY
all members of the University and the professional communities. We
therefore conduct ourselves to maintain the esteem of the University
of California and the dental profession.
B. Types of Unacceptable Behavior
1. Indiscriminate use of obscene language or gestures in the University’s
facilities
2. Failure to maintain a superior standard of personal hygiene and of
cleanliness and neatness of one’s self and one’s surroundings
whenever contact with patients is likely, such as failing to comply with
policies regarding clinic attire or failing to thoroughly clean up one’s
clinical cubicle after each use
3. Keeping a University fee paid by a patient for any dental service or
procedure
4. Requesting or encouraging in any manner gifts from patients
5. Misuse of UCSF affiliation, such as attributing personal opinions to the
School or the University
6. Misrepresenting professional status, such as using unearned
professional titles while still a student.
7. Unethical behavior when taking any licensing examination.
XI.
PROFFESSIONAL RESPONSIBILITIES TO PATIENTS
A. Ethical Principles
1. As health care providers, the students’ primary obligation of
service to patients includes delivery of competent, timely, and
supervised care within the bounds of clinical circumstances
presented by the patients and the dental school. Our conduct
Revised: Apr-11
SECTION 2 – PROFESSIONAL RESPONSIBILITIES TO THE SCHOOL OF
DENTISTRY
regarding scheduling, quality and sequence of treatment, faculty
signatures, finances, and control of infectious diseases will follow
the policies of the School of Dentistry, the principles of ethics and
code of conduct of the American Dental Association, and the
Dental Practice Act of the State of California. We recognize our
own limitations and seek the advice of those whose knowledge
and experience exceed our own. In doing so, we not only improve
the quality of care for our patients, but also expand our own
knowledge. We understand that our education does not end with
graduation but continues throughout our professional lives. The
quality of care for our patients is our primary concern.
B. Types of Unacceptable Behavior
1. Misuse of any documents related to student academic progress or
to patient care, such as failure to verify adequate supervision by
obtaining proper signatures, failure to maintain confidentiality of
patient records, removal of dental records from the clinic facilities,
or failure to promptly return records to central record storage areas
2. Refusal to comply with clinic protocol regarding patient appointment
or financial arrangements
3. Failure to comply with policies for controlling infectious diseases
4. Failure to obtain adequate faculty supervision for all phases of
patient care
5. Refusal to treat any assigned patient because of race, color, creed,
gender, national origin, sexual preference, economic status, or
handicap
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SECTION 2 – PROFESSIONAL RESPONSIBILITIES TO THE SCHOOL OF
DENTISTRY
6. Failure to make arrangements for emergency care of assigned
patients and to act as the primary source of emergency care during
clinic sessions, except when excused by conflicting classes such
as rotations or off-campus clinical assignments;
7. Failure to seek assistance when the welfare of the patient would be
safeguarded or advanced by others with special skills, knowledge,
or experience
8. Failure to report to the appropriate agency instances of gross and
continual faulty treatment by other practitioners or students and to
exercise care that such criticism is justified.
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
I. PATIENT APPOINTMENTS
A. Patients may make appointments for registration and evaluation for
comprehensive care by calling 476-1891 between the hours of 8:00 AM and
5:00 PM Monday through Friday, or by visiting the first floor reception area
between the hours of 8:00 AM and 5:00 PM Monday through Friday, except
University holidays and special events the dates of which will be posted.
B. Patients seeking emergency, walk-in care should call (415) 476-5814 for
helpful information before coming to the clinics.
II. PATIENT REGISTRATION
A. Upon presentation for the NPV appointment, the patient reports to the first
floor reception desk for intake registration. Patients are asked to read and fill
out basic registration forms, including the following:
1.
Medical History (Appendix 3.II.A.1)
2.
Dental History (Appendix 3.II.A.2)
3.
Conditions of Treatment (Appendix 3.II.A.3)
4.
Financial Policies (Appendix 3.II.A.4)
5.
Patient Acknowledgement of Receipt of Dental
Materials Fact Sheet (Appendix 3.II.A.5)
6.
Acknowledgement of Notice of Privacy Practices
(Appendix 3.II.A.6)
B. After completion of the forms, patients are issued a new, permanent and
unique chart number. This number is imprinted on a hard-copy, paper chart.
Patients' signatures for each form are captured electronically and stored on
electronic versions of the forms in the patients' Electronic Patient Record
(EPR). The virtual chart is generated upon registration of the new chart
number to the patient.
1. Hard copies of forms #1 & #2 are placed inside the paper chart. The
information from these questionnaires will be entered later by the
provider during interview at the NPV.
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
2. Mandated patient information is provided by forms #3 – 6. Patients
must acknowledge receipt and understanding of this information by
entering their electronically captured signatures.
3. Patients' demographic and account-type information is entered in the
EPR and confirmed by the reception staff. Medi-Cal eligibility is
confirmed via "swipe" of the patient's Medi-Cal card in a POS device.
Any patient unable to confirm their eligibility or insurance coverage is
categorized "CASH" account-type (see below).
C. Patients' Name and Social Security Number
1. For any changes in the patient’s demographics (i.e., change of an
address and/or phone number) notify the front desk staff, clinic
assistant or financial assistant to make the necessary changes in the
computer system. The accuracy of this information, particularly the
subscriber’s name and social security number, is vital for billing and
processing of dental insurance claims.
D. Account Types - We categorize patients' accounts into three payer types:
1.
Cash (Patients without dental insurance coverage)
2.
Private Insurance (Non-welfare coverage)
a. Indemnity type plans - Allows patients to be seen at any
California licensed dental practice
b. Restricted type plans - Such as DPO, PMI, HMO, etc. Carriers
of these plans contract directly with private dentists and
practices. Patients must seek treatment from these dentists for
full benefit of coverage from their insurance company. Dental
care at UCSF Predoc clinics is generally not covered.
c. Combination type plans – Flexible plans that provide “out of
network” coverage – These plans generally cover treatment,
but at a reduced benefit to the patient
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
3. Medi-Cal - State-funded Medi-Cal (welfare) limited coverage, for which
UCSF SOD is a service provider
4. MEDP – Medi-Cal eligible patients
E. Fees
1. All fees for treatment rendered to patients are expected to be collected
upon completion of the procedure/s. Multiple appointment
procedures, i.e. crowns, root canal, dentures, etc., require an initial
partial payment before the procedure is initiated and the remaining
balance made upon completion. Patients with an outstanding account
balance cannot schedule future appointments and any previously
scheduled appointments are automatically placed on-hold until the
account is resolved. Requests to waive such holds must be
addressed to the Financial Assistant or Clinic Directors.
III. EMERGENCY SERVICES CLINIC - Emergency Services are available for
patients of record 24 hours per day, including University holidays,
weekends and special events.
A. Definition of emergency dental condition: a dental condition manifesting itself
by acute symptoms of sufficient severity, including severe pain, which in the
absence of immediate dental attention could reasonably be expected to
result in any of the following: pain, swelling, difficulty breathing, elevated
temperature, and uncontrolled bleeding.
B. Palliative dental services during normal working hours
1. Check-in and registration occurs at the reception desk on the first floor of
the Dental Clinics building at 707 Parnassus Ave. Rm. DI000, 476-5814,
Monday through Friday (except University holidays and academic
events). Patients are checked-in on first come-first served basis from
8:30 to 12:00 n. and 1:30 to 5:00 p.m. After registration, patients are
directed to the Clinic A reception area on the second floor.
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
2. Third and fourth year dental students provide temporary treatment of
immediate dental needs and/or referrals. Clinical faculty of the
Department of Preventive and Restorative Dental Sciences and residents
of the various Postgraduate programs supervise emergency care.
Patients may receive referral to another clinical service for consultation
and/or emergency treatment.
3. Priority - No appointment is necessary for Emergency Services. Patients
with acute symptoms have higher priority than patients with non-acute
conditions. Patients may be asked to wait for treatment when the
availability of providers is low or when demand is high.
4. Financial - Patients pay for services upon diagnosis and acceptance of
the proposed treatment. No patient exhibiting acute dental conditions
such as pain, swelling or fever are refused emergency treatment because
of their inability to pay. In cases when patients cannot afford to pay when
services are provided, the patient is billed for any unpaid charges. There
is usually no charge for emergency visits resulting from comprehensive
dental care in-progress (replacing temporaries, palliative care for root
canal treatment in-progress, etc.), as long as there is no significant
interruption in care.
5. Charts - Delivery of emergency care is inefficient if a chart is not
available; students must turn in charts immediately after use.
6. Unless obligated to attend classes or assigned rotations, students are
responsible for meeting the emergency needs of their assigned patients.
The student should note the patient's complaint in the progress notes
and, preferably, meet with the patient during the ER visit or immediately
thereafter. Students should not tell patients simply to "go to the ER if
there is a problem."
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
7. Students with patient failures or who do not have a patient scheduled
during Comprehensive Care, must sign-up with the Emergency Services
clinic assistant.
IV. AFTER-HOURS EMERGENCY SERVICES – The school provides limited
emergency services for patients of record outside of normal clinic hours as
described above. After-hours ER patients should call (415) 476-5814 or the
main telephone number, (415) 476-1891 (menu selection #2). The answering
service will confirm the patient’s status and page the General Practice Resident
on-call.
A. Hours:
Monday through Friday, 5:00 p.m. - 8:00 a.m.
Saturday, Sunday and holidays - 24 hours
B. Goals of Service
1. Limited Oral Conditions: For those patients with symptoms consistent with
acute, though limited odontogenic conditions or Prosthodontic problems,
the GPR residents provide consultation, reassurance, information,
referral/directions and/or prescriptions to temporarily reduce or eliminate
acute symptoms. In addition, the patient is referred to our Predoctoral or
International Dentists Programs for clinical palliative and/or restorative
treatment during normal business hours.
2. Systemic Conditions: For those patients with symptoms consistent with
odontogenic and/or systemic conditions (i.e. advanced infection, trismus,
impaired breathing, etc.) the patient is referred to the UCSF Moffitt
Hospital Emergency Service and UCSF School of Dentistry Oral and
Maxillofacial Surgery Residents for immediate evaluation and treatment.
3. Definitions
a. Patients of Record: Patients in active, recall or related emergency
status in the Predoctoral and International Dentists Programs. These
patients should have a record of baseline or periodic (recall)
examination and an approved treatment plan within the last 3-years.
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
Also eligible are patients recently treated in the teaching program for
an emergency procedure and have persistent symptoms associated
with that condition and/or treatment.
b. Residents: General Practice Residents (GPR) are on-call with backup
and indirect supervision provided by Oral and Maxillofacial Surgery
Department (OMFS) and GPR attending faculty and program
directors.
4. Student Obligations – Students are obligated to ensure that all of their
assigned patients are familiar with the School’s regular hours as well as
afterhours/weekend ER services.
5. Any issues regarding these guidelines should be directed to Dr. Sophia
Saeed, Director of Hospital Dentistry and General Practice Residency
Programs.
V. NEW PATIENT VISIT
For purposes of this section of the Clinic Manual, we will focus on intake and
flow of patients in need of comprehensive dental care. See "Emergency
Services Clinic (section III above) for patients with urgent dental conditions.
Patients with a history of previous comprehensive dental care in the Predoctoral
Clinic do not require a New Patient Visit before resuming comprehensive care,
but should receive a Comprehensive Oral Examination (COE) or Periodic Oral
Examination (POE) based upon guidelines described in Sections X and XI
below.
A. Patients may contact UCSF by phone, in-person or by mail to initiate dental
care at UCSF School of Dentistry. The staff-person issues the patient a
temporary chart number and makes an appointment for an New Patient Visit
(NPV). The purpose and goals of the NPV are as follows:
1. Assess and document the patient's current dental condition
2. Determine the scope and complexity of the patient's immediate and longterm dental needs
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
3. Decide the appropriate level of dental provider necessary to achieve
restoration or maintenance of the patient's dental health
4. If the patient is appropriate for the Predoctoral clinics, determine the
appropriate type and amount of radiographs and/or other types of
diagnostics necessary for future Comprehensive Oral Examination
5. All data gathered and entered into Axium must receive review and
authorization by an attending faculty member. In addition, the attending
faculty must authorize all completed procedures (NPV) and planned
treatment/s, e.g. COE and radiographs, photos before the patient is
dismissed. Ideally, no patient should leave the clinic without an
appointment for the next visit and an estimate of the cost of treatment
(COE & radiographs).
6. After completion of the above, direct the patient to the Administrative
Clinic Coordinators to schedule future visits and to the reception area to
pay for any treatment costs rendered during the visit and schedule the
next visit.
B. Radiographs
1. Student-doctors should plan and receive authorization for radiographs
necessary for the subsequent COE during the NPV. In many instances,
the patient may be able to book an appointment immediately if an
opening is available in Oral Radiology. The Administrative Clinic
Coordinators (ACC) or front desk receptionists can call the Oral
Radiography Service for a request for an immediate opening reservation.
If an opening is available, the patient should be escorted to the reception
area to make payment for the radiographs. The staff will enter the
patient's payment in Axium and direct them to the first floor reception
desk, where a staff member or student-doctor on rotation will retrieve
them for imaging.
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
2. Original or duplicate radiographs from outside providers require upload
into Axium. Supplemental films may be necessary to make them of
sufficient diagnostic quality. Fees for conversion and supplemental films
are charged according to prevailing fees.
C. Student appointment scheduling in Axium (How to) - To schedule a patient
appointment: Click the Scheduling icon
1. Click the “Active” tab
2. Change display to the planned date for the appointment
3. Click the schedule at the appointment start time and the “Rolodex (Select
Patient)” window will display
4. Enter the patient’s chart # or select from the list on the right
5. “New Appointment” window will display
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
6. “Appt. Code”: click arrow to select the appointment length from dropdown menu
7. Click “Tx. Plan” button on the right-side of window:
a. Click “Tx. Plan” button on the right-side of window:
b. Double-click items from the Treatment Plan that describes this
planned appointment
i.
Items with a checkmark are attached to another
appointment
ii.
Treatment plan items display for the Start Check and let
staff know amount to collect from the patient at check-in
c. Click “Close” when complete
8. Reason/Note: Enter brief appointment description
a. Displays on screen and print out
9. If patient will accept “Sooner if Possible” or “Short Notice,” click box to
select
a. This will provide a list for staff to use to fill open slots on your
schedule
10. If a recall appointment, check “Recall” box and click “Recall” button to
select recall for this appointment
11. Click “Accept” button when all info is complete
a.
Window will close and appointment displays as yellow box
12. Left-click, hold and drag the appointment to the start time
13. Double-click to save the appointment; turns white when saved
14. Appointments booked by providers: times can be modified by doubleclicking to open and change the amount of time (“Appt. Code”). By rightclicking an appointment, you can reschedule, cancel, fail and delete it.
15. Appointments booked by staff cannot be changed or deleted
16. Please see your Clinic Coordinator to book an appointment time with
specialists
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
VI.
PATIENT ASSIGNMENT - students may be assigned patients by several
mechanisms:
A. NPV - Assignments are made based on the mutual needs and
availability of both patients and students. The course and clinic
directors will work together to assess and update each student's
clinical needs over the course of their clinical experiences. Students
should use the Administrative Action Form to keep the clinic directors
advised of their current and future needs.
B. TRANSFERS - Patients may be transferred from one student to
another with the approval of a coach, course director or clinic director
by means of an authorized AAF. Student to student transfers are
based primarily on the student linkage system. Exceptions to the
student linkage transfers will be made based on patient language
requirements, complexity of dental needs, availability and other factors
as determined by faculty authorized to approve patient transfers.
1.
The bulk of patients assigned to incoming third and fourth-
year students come from redistribution of patients previously
assigned to students graduating in the spring or summer
quarter. Each graduating student, with oversight and approval
from their coach, is required to assess each of their assigned
patient’s needs and transfers active and recall patients to
incoming students as part of the Graduation Clearance
process.
C. CLINIC DIRECTORS - As needed, the Predoctoral clinic directors will
assign patients to students. These patients may be former patients of
the Predoctoral clinic seeking reassignment and treatment, patient
transfers from other students or clinics (e.g., Buchanan Dental Center,
Pediatric Clinic) or patients being referred from specialty programs/
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
clinics for co-treatment (e.g., PG Perio, PG Ortho, PG Pros or PG
Pediatrics)
D. Notifications of assignments are sent directly to student’s axiUm emailbox whenever a staff or clinic director makes an assignment
change via the axiUm “Patient Info” window. Students should also
review their monthly Patient Assignment Reports carefully for entries
of new patient assignments.
VII.
STUDENT RESPONSIBILITIES TO ASSIGNED PATIENTS
A. Students are responsible for the care of all clinic patients assigned to
them. Welfare of the patient is the provider’s primary concern. The
student is responsible for knowing and applying knowledge of the
patient's medical and dental history and conditions, including caries
risk, in the planning and rendering of dental treatment.
B. Each patient is assigned a student who has the primary responsibility
for planning, managing and providing comprehensive dental care to
that patient. Once assigned, other providers (students, residents and
faculty) may co-treat the patient by arrangement of the primary
provider and under the direction of the attending faculty/coach or clinic
director. Patient care must be managed in a timely manner with active
patients receiving treatment approximately once a month.
C. A student may not unilaterally reschedule a patient appointment made
by patient intake or clinic personnel without authorization of the clinic
director.
D. Students may never treat patients outside of regular clinic hours or
without proper faculty supervision. To do so is a violation of the
Student Honor Code. Such activity will result in severe disciplinary
actions, including loss of clinic privileges and possible expulsion. In
addition, such activity voids the University’s professional liability
coverage.
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
E. Students may never treat patients outside of University sanctioned
facilities, i.e. non-affiliated offices, mobile clinics, homemade
operatories, etc. To do so is a violation of the Student Honor Code.
Such activity will result in severe disciplinary actions, including loss of
clinic privileges and possible expulsion. In addition, such activity voids
the University’s professional liability coverage.
F. Unauthorized persons are not permitted to participate in providing
patient care or to observe clinical procedures
G. See section 2. PROFESSIONAL RESPONSIBILITIES TO THE
SCHOOL OF DENTISTRY
VIII.
PATIENT DISTRIBUTION
A. Patients will be assigned to students in a fair and systematic manner
in an attempt to facilitate students’ ability to complete their clinical
course requirements and expectations in a reasonable period.
B. Whenever possible, transfer patients will be assigned with the idea of
matching the needs and availability of the patient with the skill level,
needs and availability of a student. To aid the student-patient
assignment decision, authorized faculty and clinic directors will assess
pre-existing treatment plans.
C. Primary providers that exceed the maximum number of assigned
Active and Recall patients must demonstrate those patients are
properly managed.
D. If, in the opinion of the clinic or course director or in consult with the
attending faculty it is in the patients’ best interest of quality dental
care, some patients may be co-assigned or transferred to other
students.
E. Students that exceed their maximum number of assigned Active and
Recall patients may have their ‘abandoned’ patients transferred to
other students by authorized faculty for appropriate care.
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
F. Patient distribution profiles for each student will be monitored by his or
her coach. As part of appropriate patient management, the coach will
complete a formal periodic review of each student’s patient
assignment list to ensure a proper status designation and timeliness of
care for each patient. As recommended by the coach, patients may
be transferred to or co-treated with other students to provide
appropriate and timely care.
IX.
INTAKE POLICY FOR FAMILY AND FRIENDS - This policy establishes
guidelines for dental students to treat family members and friends at the
UCSF School of Dentistry Parnassus clinic. Family and friends must enter
the clinic through the New Patient Visit (NPV) process to ensure that their
level of dental treatment needs is within the scope of the Predoctoral clinics.
A. Students who wish to request assignment of family and friends should
submit an Administrative Action Form (AAF) to Clinic Director for
authorization.
B. Give the authorized AAF to the first-floor reception desk staff, who will
initiate the registration process and create an electronic chart. All
other aspects of intake are as per usual. No special discounts or
considerations are offered to family and friends with the exception of
student’s immediate family (spouse, children and dependents).
X.
COMPREHENSIVE ORAL EXAM (COE) - This examination establishes the
patient's baseline medical and dental conditions upon presentation to the
Predoctoral Comprehensive Care Dental Clinic
A.
Requires Registration and NPV - All patients must register and
have an NPV before receiving a COE in the Predoctoral Clinics.
Students may not provide care for unregistered patients or when
students are not supervised by a licensed or permitted UCSF
attending dentist.
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
B. Appointments and Patient Flow
1. All appointments must be scheduled in Axium and should have
an appointment description
a. The font color of the scheduled appointment appears GREEN
b. Once confirmed, the appointment entry font changes to BLUE
2. All appointments will be entered using the times indicated on the fee
schedule, i.e. the POE scheduled appointment time is 90 mins.
3. All patients must check-in at the second floor front desk (Staff updates
demographics, insurance information, eligibility check, collects
payment for scheduled procedures, and directs the patient to the
financial assistant if necessary)
a. The font color of the appointment changes to RED upon checkin
b. This signals the student-doctor of the patient's check-in and
ready for retrieval from waiting area/room
4. Student-doctor retrieves patient from the waiting area
5. After the appointment, provider should charge-out the procedure in
Axium and generate a Progress Note, including description of the next
visit
6. Obtain all authorizations from attending-faculty
7. Bring your patient to the clinic assistant to schedule the next visit
(procedure must be planned in Axium)
8. Escort your patient to the front desk to check out (pay for charged-out
procedures, provide financial information or direct to financial
assistant)
a. Patient checkout is indicated in Axium by a change in font color
to GREY
b. If the patients fails to check out, their entry remains RED
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
9. The goal should be to provide every patient a future appointment, no
account balance and an estimate of treatment planned for next visit
C. Forms - Patients complete hard-copy versions of the Dental and Medical
History forms during registration. Providers must transfer the information
contained on these forms into the Axium Electronic Health Record during
the NPV or COE. At the COE appointment, ensure the information is
current and signed by the patient. Offer to answer any questions the
patient may have regarding registration forms they received. The
following electronic forms must be completed by the provider, signed by
the patient, and authorized by the attending faculty for each patient
undergoing a COE:
1. Dental History
2. Medical History
3. Clinical Findings Examination and Odontogram – COE_Exam
Inst_PCC129_2007.ppt
4. Periodontal Charting – COE_Perio Charting Inst_PCC129_2007.ppt
5. Caries Risk Assessment – COE_Caries Risk Assess
Inst_PCC129_2007.ppt
6. Specialty Consults
7. Treatment Plan Module – COE_TX Plan Module
Inst_PCC129_2007.ppt or use the NIS version: EHR - UC
Edition_Revised_2007.pdf, pages 20 - 28
D. Diagnostics
1. Diagnostic quality radiographs must be present to evaluate and
document the patient's hard tissue
2. Mounted Study Casts may be necessary to evaluate the patient's
occlusal relationship, complexity of care and suitability for the
Predoctoral Clinic
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
3. Photographs may be necessary to document the patient's physical
presentation, esthetic considerations or intraoral soft or hard tissue
conditions not presentable by other medium.
E. Tentative Treatment Plan - Provider must generate a tentative treatment
plan for consultation with attending faculty. Once the patient, provider
and attending agrees with the tentative treatment plan, the faculty
provides authorization of the treatment plan module.
F. Fee Increases - We strive to provide services at a reasonable cost.
However, as costs to provide dental care increase, the School is
obligated to raise fees periodically. Dental procedures initiated prior to
fee increases will be honored at the fee in effect at the time treatment is
initiated (as long as no significant interruption in care occurs). Treatment
planned prior to but initiated after the fee increase will be charged at the
increased fee. Any questions regarding financial arrangements should be
clarified prior to initiating treatment. Given the possibility of fee
assessments to the student-doctor, it is unwise to proceed with dental
procedures with questionable financial arrangements.
G. Interruptions in Comprehensive Care - Patients with a history of previous
comprehensive dental care, which is interrupted for three years or more,
should receive a COE before resuming comprehensive care. Patients
with a history of previous comprehensive dental care in the Predoctoral
Clinic, but had an interruption in comprehensive care for less than three
years, should receive a POE before resuming comprehensive care.
XI.
PERIODIC ORAL EXAMINATION (POE) - Patients with a history of previous
Comprehensive Oral Examination and dental care in the Predoctoral Clinic
and placed on RECALL or had an interruption in comprehensive care less
than three years, should receive a POE before resuming comprehensive
care.
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
A. The following electronic forms must be updated by the provider, signed by
the patient, and authorized by the attending faculty for each patient
undergoing a POE:
1.
Medical History
2.
Clinical Findings Examination and Odontogram –
COE_Exam Inst_PCC129_2007.ppt
3.
Periodontal Charting –
COE_Perio Charting Inst_PCC129_2007.ppt
4.
Caries Risk Assessment –
COE_Caries Risk Assess Inst_PCC129_2007.ppt
5.
Specialty Consults
6.
Treatment Plan Module –
COE_TX Plan Module Inst_PCC129_2007.ppt or
use the NIS version: EHR - UC Edition_Revised_2007.pdf,
pages 20 – 28
XII.
FINANCIAL POLICIES & PROCEDURES - All patients receive a Financial
Policy Statement upon registration. It is the responsibility of the studentdoctor to review the document with the patient to insure the patient
understands and accepts the terms of the policy statement. Providers and
patients are encouraged to discuss financial questions with the Financial
Assistant or the Administrative Clinic Coordinators. Clinic Directors can
provide clarification or interpretation of the financial policies when issues that
are more complex arise.
A. The Predoctoral Clinics is a cash or "pay as you go" comprehensive
dental care clinic. It is the responsibility of each student-doctor to
maintain a balance of production and financial arrangements such that
each of their comprehensive care patient's account balance is zero or has
an account credit for in-process dental procedures. Patients with an
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
outstanding balance, reflects poor patient management and requires
corrective intervention by clinic administration.
B. Production, Equivalent Amounts – Gross fees generated for dental
services delivered
1.
Production is a valuable metric for quantifying the learning
experiences to which each student-doctor is exposed. This report
includes all procedures properly entered into AxiUm, approved by
the attending faculty member supervising treatment and allocated
to a patient's account. This report does not reflect discounts or nocharged treatments. NIS generates production reports and
distributes them to the appropriate course directors on a quarterly
basis.
C. Unapproved Treatment - Unapproved treatment is procedure/s charged
out without authorization by an attending faculty.
1.
Student-doctors with Unapproved Treatment as reported by NIS
are barred from registration for the upcoming quarter.
2.
To remove Unapproved Treatment, student-doctor must have
attending faculty approve (provide e-signature) each in-process
and completed procedure that is without authorization.
3.
Present completed report to Office for Clinic Administrative
Services (OCS), Dave Gonzalez (D1000). OCS will contact Burton
Ober, Student Services, to remove registration holds.
D. Unallocated Payments - Unallocated payments are patient payments for
unapproved treatment. As such, the unspecified payment remains in the
patient's account until allocated to an approved treatment. Unallocated
payments have the effect of a non-specific credit, which reduces the
patient's account balance.
E. Accounts Receivable (AR): Money owed to the School for services
completed or in-process.
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
1. AR is a valuable metric for quantifying a student's patient
management skills and compliance to clinic policies and
procedures. NIS generates AR reports and distributes them to
the appropriate course and clinic directors on a quarterly basis.
2. Students are responsible for maintaining their patients'
collective AR below $500.
3. Student-doctors with a collective AR exceeding $500, as
reported by NIS, are barred from registration for the upcoming
quarter.
4. To remove excess AR, student-doctor must facilitate an
effective financial arrangement that eliminates their patient's
outstanding balance.
5. Present completed report to Office for Clinic Administrative
Services (OCS), David Gonzalez. OCS will contact Burton
Ober, Student Services, to remove registration holds.
6. Patients with outstanding balances are placed on discontinued
status until their outstanding balance is zero. Patients may not
make future appointments in the comprehensive care clinic if
their account is in arrears.
F. Outstanding Balances - Students are not allowed to provide dental
services for patients with an outstanding balance. Any such treatment
rendered by the student-doctor will result in disciplinary action, which
includes financial responsibility for the treatment costs and possible loss
of clinic privileges.
G. Fee Increases - We strive to provide services at a reasonable cost.
However, as costs to provide dental care increase, the School is
obligated to raise fees periodically. Dental procedures initiated prior to
fee increases will be honored at the fee in effect at the time treatment is
initiated (as long as no significant interruption in care occurs). Treatment
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
planned prior to but initiated after the fee increase will be charged at the
increased fee. Any questions regarding financial arrangements should be
clarified prior to initiating treatment. Given the possibility of fee
assessments to the student-doctor, it is unwise to proceed with dental
procedures with questionable financial arrangements.
XIII.
PATIENT MANAGEMENT RESPONSIBILITIES
A. Charge Entry – Every patient visit must have an accompanying
transaction entered in Axium
1.
All charge entries must have diagnosis and prognosis codes
entered
2.
All entries must receive attending-faculty authorization (esignature)
3.
Failure to schedule patients properly, improper charge entry and
failure to obtain faculty approval are unprofessional conduct for
failure to follow clinic policies and procedures. Such violations will
result in clinic suspension, barring from registration and possible
dismissal from the School of Dentistry.
B. Appointment Entry – All patient visits must be entered into Axium and
patients must check-in at front desk prior to seating
1.
Patients seated in cubicles without proper entry into Axium and
check-in at the front desk will be dismissed from the clinic
2.
Students seating or treating patients not properly entered into
Axium and checked-in are subject to immediate suspension from
the clinic
3.
Cubicles are subject to reassignment if student-doctor and/or
patient fail to follow appointment protocols
C. Missing Charges - NIS distributes Missing Charges reports on a daily
basis for follow-up on patients scheduled an appointment the previous
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
day, but did not have charges entered. Every patient must have a facultyapproved entry for each visit in Axium.
1.
Administrative Clinic Coordinators (ACC’s) assist in the process of
ensuring follow-up and entry of these charges. After the studentdoctor completes the Missing Charges report, return it to your
ACC. The ACC will monitor the Missing Charges report to ensure
patient records are accurate and up to date.
D. Broken Appointments
1.
If a patient fails an appointment or arrives more than twentyminutes late (after the scheduled appointment time) to an
appointment, enter a Broken Appointment charge, attach a note in
the EPR and obtain authorization from attending faculty.
2.
A Broken Appointment charge automatically generates a letter to
the patient documenting the broken appointment, reminds them of
the School's attendance policy, charges the patient a broken
appointment fee and warns the patient that two broken
appointments is grounds for discontinuance from the Predoctoral
Clinic.
E. Chair Reservations and Grace Period (See Conditions of Treatment)
1.
Clinic Administration reserves Predoctoral Clinics chairs for 3.5
hour clinic sessions to registered students enrolled in PCC 139,
149 and PCC 106 courses. Morning clinic sessions begin promptly
at 8:30 a.m. Afternoon clinic sessions begin promptly at 1:30 p.m.
2.
We grant patients a grace period of 30 minutes to check-in and
occupy the chair reserved for their appointment. After this grace
period expires, the student must charge-out a broken appointment
to the patient and the chair is subject to reassignment to another
provider/patient (see Standby section below).
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
3.
To maximize your clinical experiences and productivity, multiple
patient visits during the clinic sessions are encouraged. However,
appointments must be scheduled at the beginning of the clinic
session (8:30 a.m. or 1:30 p.m.) to reserve the cubicle. Do not
appoint patients at odd times (9:30 a.m., 10:00 a.m., 2:30 p.m. or
3:00 p.m.) and leave an empty schedule at the beginning of the
clinic session. If the patient cannot come in at 8:30 a.m. or 1:30
p.m., your chair may be re-assigned to another provider (see
Standby section below) or you will be expected to see an ER or
NPV patient.
4.
PCC courses requires students to remain in the Predoctoral Clinics
during their assigned clinic sessions. Depending upon the overall
demand for chairs at that session and direction of the attending
faculty, they may see ER/NPV patients, assist other providers
within their team, assist other providers within the clinics or
contribute to the clinical enterprise in some way determined by the
attending faculty. Students must notify the attending or ACC if
they leave the clinic floor and leave means to contact them if the
need arises.
5.
Reserved ISO chairs are treated exactly the same as PCC chairs,
in that, any student reserved a chair must provide patient care for
the entire clinic session. Failure to attend or remain throughout the
clinic session, is counted as an absence towards the PCC course.
6.
Any student who leaves the clinic without authorization from the
attending faculty is in violation of the Student Honor Code and
subject to disciplinary actions, which may include fines, loss of
clinic privileges and expulsion from the School of Dentistry.
F. Standby - To better utilize available chairs and to increase efficiency, we
have implemented a cubicle "standby" system. We are trying to reduce
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
or eliminate the loss of student experiences and production opportunities
resulting from under-utilization of the clinic chairs. A total of 15 chairs are
open for standby signup each clinic session.
G. Signup Procedure - Students must submit an Administrative Action Form
with a designated patient and procedure type to an Administrative Clinic
Coordinator. Patients with an account balance are ineligible for standby.
1. Students taking advantage of this option of scheduling are
obligated to make it clear to their patients before scheduling on
standby that chair availability is not guaranteed. If no chairs
become available, patients should understand the process and
accept the possibility that they may not receive care during the
session.
H. Chair Distribution
1.
The standby chairs are assigned to students/patients on the signup
list when "unutilized" chairs are distributed after the grace period
expires (see Chair Reservations section above).
2.
After the 20-minute grace period, all cubicles without a scheduled
patient or patients who fail to check-in, change color to red in the
Axium Scheduler window. This identifies cubicles to which the
ACC can assign standby students. The ACC will notify the
attending faculty in the appropriate teams when standby chairs
have been distributed. This allows the attending faculty to better
manage the patient care activities of the team members as well as
resolve any problems that may arise from cubicle redistribution.
3.
Patients occupying chairs, but failed to check-in, will be asked to
check-in at the reception desk and an incident report will be filed
4.
Students found not adhering to the protocol for chair distribution
are in violation of Clinic Administration and Clinical Courses
policies as well as the Student Honor Code and are subject to
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
disciplinary actions, which may include fines, loss of clinic
privileges and expulsion from the School of Dentistry.
XIV.
PATIENT STATUS - Patient Status is a designation of patients' relative
dental condition and treatment status in the Predoctoral dental teaching
clinic. The current status designations are: Active, Recall and
Discontinued.
A. Active - Patient has dental conditions, which require regularly scheduled
visits for Phases I – III dental prevention and/or treatment with assigned
primary and/or secondary provider. Patient's appointments occur at least
once every two months. Active care is uninterrupted and continuous at a
pace that is acceptable to both the patient and the provider/s.
1. Active patients have access to Emergency Services during normal
business hours, as well as, after-hours.
2. PHASES OF CARE for "Active" patients
a. I – Disease Control, Diagnosis and Prevention
b. II – Simple Restorative and esthetics
c. III – Tooth Replacement and stabilization
3. PHASES OF CARE for "Recall and Inactive" patients
a. IV - Maintenance
b. Discontinued (Inactive)
B. Recall - Recall status is characterized by patient's in general dental health
and maintenance, Phase IV. Patients must be recalled on a regular basis
(2 – 12 months) to maintain periodontal health and periodic oral
examination.
1. Recall patients have access to Emergency Services during regular
business and after-hours
C. Discontinued, Voluntary - [Miscellaneous (P0967), Financial (P0963),
Dissatisfied w/ Treatment (P0964, Dissatisfied w/ School/Process
(P0965), Unable to Contact Patient (P0962)]
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
1. Patients voluntarily separated from the Predoctoral Clinics may
return to Active or Recall status at their request. However, while
they are in discontinued status they are not patients of record and
may not book future comprehensive dental care appointments nor
receive assignment to a primary provider in the Predoctoral clinics.
2. Patients voluntarily discontinued may have access to business
hours Emergency Services, but do not have access to after-hours
Emergency Services.
3. Interruptions in care may result in automatic Discontinuance with
Letter of Interest (Transaction code: P0962). Specifically, any
patient with Active status, but no appointment within six months,
will have status changed to Discontinued and a letter will be sent to
the last known address in the patient management system to
determine the patient's interest in resuming active care. Patient
status will remain inactive until the patient responds to re-initiate
active status and make a future appointment.
D. Discontinued, Involuntary - [Attendance (P0966), Do Not Re-appoint
(P0999)]
1. Patients discontinued for cause and involuntarily separated from
the comprehensive care clinics may not book future appointments
nor receive assignment to a primary provider in the Predoctoral
clinics. Access to Emergency Services during normal business
hours is determined on a case-by-case basis.
2. Patients in this status designation do not have access to afterhours Emergency Services.
XV. TRANSFER OF PATIENTS BETWEEN PREDOCTORAL CLINICS - As a
rule it is possible to move patients from one clinic to another. However, any
request for a patient transfer requires approval by a Clinic Director or faculty
responsible for patients’ management. When it becomes necessary to transfer a
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
patient to another clinic site, it is important to avoid confusion or inaccuracies in
the patient’s clinical and financial records. Following the procedures outlined
here will make it possible to see a patient at the Parnassus campus and/or
Buchanan Dental Center (BDC). This allows proper billing of the treatment as
well as tracking the location of the physical chart, if one exists. Physical charts
are tracked by means of the axiUm Chart Locator system, which, if used
properly, ensures the patient’s treatment needs are addressed without
interruption, delay or duplication of records.
A. Parnassus to BDC - Initiator’s Responsibilities:
1. If a student initiates the patient’s move to BDC, the student must
complete and submit to the Administrative Clinic Coordinator
(ACC) a Predoctoral Patient Referral/ Transfer Form. The ACC,
with assistance from the Financial Assistant (FA) and/or Clinic
Director, will document that patient has no in-progress procedures,
which may be compromised or delayed by the move to another
clinic, or outstanding account balances.
2. Place a note placed in the patient’s EHR progress notes indicating
the reason for transfer, new location and program and plans for
future comprehensive care
B. Clinic/Financial Assistant’s Role: The clinic/financial assistant must review
the account history. If there is a balance due, the account balance must
be resolved before the chart/patient is transferred. Questions concerning
whether a chart should be sent to another clinic with an account balance
will be resolved by the Clinic Director. If there is a credit balance on the
account, the originating clinic will refund the patient, transfer the credit
balance to the new clinic or leave the credit balance in the originating
clinic if the patient plans to resume comprehensive care at Parnassus in
future.
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
1. Send request to the record room to transport contents of the
physical chart stored in the record room to the treating clinic. If the
chart is “purged” (no treatment or use of physical chart within past
two years) and stored in an off-site storage facility, DO NOT
request its retrieval unless it is known to or suspected of containing
significantly useful information.
C. ”New” Clinic’s Role: When the chart arrives at the new clinic, the
appropriate staff member will input new chart location in axiUm locator
system
1. Update axiUm Patient Card to reflect to which clinic, program and
provider the patient will be assigned. For example, if a student is
already assigned to the patient and will provide continued care in
the new clinic, no change of the provider assignment is required. It
is important that this procedure be followed so that the Patient
Assignment Report will accurately reflect provider assignments
and the Patient Card will accurately reflect treatment locations.
XVI. REFERRAL OF PATIENTS TO ORAL MEDICINE CLINIC
A. Student Consultation Protocol - The UCSF Oral Medicine faculty will
provide a consultation at no charge to a patient seen in the Predoctoral
clinics under the following conditions:
1. The student must call the Oral Medicine clinic at 476-2045 before
10:30 am for a consult during the morning clinic and before 3:00
pm for a consult during the afternoon clinic (note: there are no
clinic sessions on Friday afternoons).
2. The student must accompany the patient and participate in the
work-up, present the case to the attending faculty, and write-up the
oral medicine chart under the attending faculty’s guidance.
3. The student should bring the dental chart from the student clinic in
case existing radiographs need to be examined by the oral
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
medicine faculty. (Note: Comp Care Clinic chart must be returned
to the record room immediately after consult)
4. Only the initial visit will be free of charge to the patient.
Subsequent follow-up visits and/or biopsy procedures will be billed
to the patient or his/her insurance carrier.
5. If a student does not accompany a patient, the student should write
a referral letter, which the patient should bring with any other
relevant information (e.g., radiographs should be submitted if
pertinent). If a student does not accompany the patient, a
consultation fee will be billed to the patient or his/her insurance
carrier.
XVII. STUDENT-PATIENT LINKAGE SYSTEM
A. What is the student-patient linkage system?
1. The linkage system is our way of arranging care for our patients by
linking them, in an orderly fashion, to students. Academically, this
system provides continuity of care for patients and gives students
direction for co-treatment, referral and transfers to specific
students.
2. The linkage system identifies and arranges dental students
vertically through their years of clinical experience so that students
who have the training to meet their needs can treat patients.
Fourth year dental students (DIV and IDIV), third year dental
students (DIII and IDIII) and second year dental students (DII) are
connected by the identified pairings. The linkage is printed on the
linkage spreadsheet and is distributed to students and supporting
faculty on a periodic basis.
B. When is the linkage system utilized?
1. The linkage system is utilized for all patients on a student’s patient
assignment list from the time that the Comprehensive Oral
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
Examination or Periodic Oral Examination is completed until the
student transfers the patient to another provider or discontinues
the patient. Academically, it is expected that at the completion of
the examination, that the student and faculty have identified the
needs of the patient, discussed risks, benefits and ideal/ alternative
treatment, and reached an agreement with the patient on the
definitive treatment plan (documented on the Procedure Plan
form). It is at this time that the student will utilize the linkage
system to identify which provider will be responsible for specific
procedures listed on the Procedure Plan form, and accurately
identifies them in the computer treatment plan. In addition, the
computer database should identify the primary, secondary and
tertiary providers as appropriate for completing a patient’s care in a
timely manner. The providers may be a mixture of dental students.
C. Where is the linkage system utilized?
1. The linkage system is utilized in the Predoctoral Patient Centered
Care Clinics at Parnassus and the Buchanan Dental Center.
Specific courses in which students are expected to utilize the
linkage system are PCC126, PCC139, PCC149 and PCC106.1
and PCC 106.2.
D. How is the linkage system utilized?
1. Faculty, students and staff utilize the linkage system by looking up
on the linkage spreadsheet the student pairings and identifying all
of the student connections. The Administrative Clinic Coordinators
enter these linkages into the computer. The student primary care
provider then utilizes these linkages to identify specific patient
treatment responsibilities for the various providers.
Examples of appropriate linkages are:
Primary:
DIV
DIII
IDIII
IDIII
IDIII
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
Secondary: DIII
Tertiary:
DII
DII
DII
DIII
DIV
DIV
E. Why do we utilize the linkage system?
1. The linkage system is utilized to provide continuity of care for our
patients. It is expected that students will utilize the linkage system
for the majority of their patients and demonstrate proper practice
management. The linkage system provides a mechanism for
students to have balanced patient assignment lists and for patients
to have continuity of care after students graduate. By utilizing the
linkage system, patients receive comprehensive care by a series of
providers, with continuity over their years of treatment.
F. How does the practice management exercise affect the linkages?
1. Fourth and third year dental students, at least twice per year, have
as a practice management exercise the responsibility of identifying
the linkages for all of their patients on their patient assignment list.
At these times, patient needs are reassessed and appropriate
changes to their linkages are made, with faculty concurrence. It is
expected that the vast majority of patients will keep their linkages
the same, but some modifications may be needed if there are
specific patient needs, such as language or behavioral dentistry
considerations.
2. In the spring quarter of the fourth year, graduating students will
utilize the linkage system to transfer all of the patients on their
patient assignment list, arranging continuity of care and identifying
the primary, secondary and tertiary providers.
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
G. Policy on Co-treatment Among Linked Students at Parnassus Predoctoral
Clinic
1. When appropriate, a student may enlist the help of linked (dental)
students to provide care. The following are policies that govern
this action:
a. Dental students are responsible for the comprehensive care
of each assigned patient. Treatment may be shared with
linked dental students with the agreement of the attending
faculty.
b. The primary student-dentist assigned to the patient must
complete the diagnostic procedures, develop the Treatment
Plan and enter the Treatment Plan in axiUm for that patient.
c. Co-treatment should be within the linkages whenever
possible
XVIII. STUDENT, FACULTY AND PATIENT EYEWEAR POLICY
A. All students, faculty and patients must wear appropriate protective
eyewear during patient care activities:
1. Plastic goggles with side shield protection works well for
individuals with or without prescription glasses. Wearing
prescription glasses without side shield protection is not
acceptable.
2. If you wear prescription glasses and the plastic goggles do not fit
well or are uncomfortable, a clip-on face shield may work better for
you. Another option is the disposable “Googles” plastic eyewear,
which can be worn alone or over prescription eyewear.
3. If you wear "Loupes” -type magnification glasses, please make
sure the manufacturer has provided you with the attachable hard
plastic side shields. “Loupes” without side shields protection is not
acceptable.
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
4. Students may purchase the clip-on face shields or "Googles" from
the Student Store at a reasonable sales price. As a courtesy to
faculty, they may request a clip-on face shield or “Googles”
eyewear from the clinic dispensary.
5. Patients must use eyewear or other means of eye protection
during all procedures when the chair is reclined.
XIX. PROPER INSTRUMENT ARRANGEMENT AND PLACEMENT IN THE
OPERATORY
A. Dental instruments must be sterilized and properly arranged in cassettes
when used in the dental operatory. Instruments in cassettes can be
placed on the stainless steel instrument tray holder, which is attached to
the patient care delivery system (air/water syringe, saliva ejector, high
volume evacuation, high/low speed hose connections). In addition,
instruments in cassettes and/or equipment may be placed on a utility cart
or countertop if needed for completion of a dental procedure. Please use
“overgloves” if you need to access a supply item, material or instrument
from the countertop or mobile cart.
B. Clean instruments, supplies or equipment must not be placed near the
sink, which is considered a contaminated zone. Please keep clean items
at least 12-inches away from the sink to avoid the contaminated “splash”
zone.
C. Instruments should never be placed on a patient’s chest while providing
patient treatment. Often patients object directly, file a complaint after-thefact or endure the discomfort caused by this poor technique.
D. All instruments should be returned to the cassette tray(s) during and after
patient treatment.
XX. NITROUS OXIDE/OXYGEN PORTABLE UNIT USE - POLICY &
PROCEDURES
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
A. Policy - The attending faculty is responsible for reviewing a patient’s
medical history, determining patient risk for the administration of nitrous
oxide/oxygen (N2O/O2) sedation, and properly supervising the students
in the use of N2O/O2 sedation in patient care activities. The faculty is
responsible for overseeing the equipment set-up and hookup of the
N2O/O2 portable units to the dental operatory. Faculty should be
comfortable and competent in the use of N2O/O2 sedation, understand
the indications and contraindications for clinical use and be prepared to
address a possible medical emergency. A faculty signature in a patient’s
Progress Notes will be required for students to check out N2O/O2
portable units from the clinic dispensary.
B. Procedures:
1. Student obtains faculty signature on a “Dispensary Prescription
with Faculty Signature” request authorizing the student to checkout the N2O/O2 portable unit from the dispensary
2. Student is responsible for inspecting the N2O/O2 tank tags, which
indicates whether the tanks (two O2 and two N2O tanks) are “Full”,
“In-service” or “Empty”
3. Using this information, the student is responsible for checking the
tank gauges to determine the amount of nitrous oxide and oxygen
PSI left in the tanks
a. For a three-hour patient care session, you will need a
combined tank content of 2500 PSI for oxygen and 850 PSI
for nitrous oxide. If you have less than the ideal oxygen and
nitrous oxide PSI, then you should be prepared to complete
a dental procedure in less than three-hours or use an
additional or different unit.
4. After completing steps 1, 2, 3, the student informs the clinic
dispensary personnel of the nitrous oxide unit number selected.
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SECTION 3 – PATIENT CARE RESPONSIBILITIES
The clinic dispensary personnel will note the student ID#, cubicle
and unit # and dispense the rubber mask attachment.
5. Clinic dispensary personnel will “unlock” the designated N2O/O2
unit. The student will move it to the appropriate operatory,
complete the hook up procedure and correctly adjust the
scavenging system. The faculty should check the equipment setup
as part of their oversight responsibility.
6. After proper equipment hook-up in the dental operatory, the
attending faculty is responsible for providing detailed instruction to
the student on the safe administration of N2O/O2 sedation to a
patient. The faculty should monitor the patient to ensure a stable
and safe sedation level. The student (or assistant) should never
leave the patient alone and unmonitored during N2O/O2
administration. The faculty is responsible for overseeing the safe
recovery of the patient prior to dismissal from the dental operatory.
7. The student is responsible for the proper disinfection of the
N2O/O2 portable unit and the return of the unit and attachments to
the clinic dispensary. In addition, the student is expected to
change the tank tag as appropriate. If a N2O/O2 tank was “Full” at
the beginning of administration, then partially used, tear-off the
“Full” tag. The remaining tank tag should now read “In-Service.” If
the N2O/O2 tank was “In-Service” and now is depleted, then the
“In-Service” tag should be torn-off. The remaining tank tag should
now read “Empty.” If a tank is empty, please report this fact to the
clinic dispensary personnel. The Facilities Unit, Mechanicians staff
performs regularly scheduled tank/unit servicing.
8. Students should ensure that dispensary staff document return of
the unit to the dispensary.
Revised: May-11
SECTION 4 – DENTAL PATIENT BILL OF
RIGHTS AND RESPONSIBILITIES
I.
The Patient Rights and Responsibilities printed below apply to every patient
in our clinics with the understanding that the University of California, San
Francisco, in conformance with the applicable laws and regulations, does not
discriminate on the basis of race, color, national origin, gender, handicap,
sexual orientation, or age. We encourage patients to be informed about all
aspects of their care. Your dental care provider and teaching faculty are the
best persons to ask about the treatment and care you receive at the school.
A. All Patients Of The School of Dentistry Have A Right To:
1. Considerate and respectful care
2. Know the name of the dental care provider
3. Be informed of risks as well as the nature of procedures,
expected benefits, and the availability of alternative methods of
treatment and the risk of no treatment
4. Ask your dental provider to discuss all the treatment options
regardless of coverage or cost
5. Know in advance the type and expected cost of treatment
6. Examine and receive an explanation of the statement of
charges
7. Be informed of continuing dental health care requirements
8. Reasonable continuity of care and completion of treatment
9. Expect dental team members to use appropriate infection and
sterilization controls
10. Privacy concerning the dental care program
11. Confidentiality of all communications and records pertaining to
care. You are entitled to access the information contained in
your patient record, within the limits of the law
Revised: Apr-11
SECTION 4 – DENTAL PATIENT BILL OF
RIGHTS AND RESPONSIBILITIES
12. Have these patient rights apply to the person who may have
legal responsibility to make decisions regarding dental care on
behalf of the patient
13. Treatment that meets the standard of care
14. To express concerns or complaints about your care with the
assurance that the presentation of a complaint will not
compromise the quality of your care
15. Exercise these rights and have reasonable access to treatment
in our clinics
B. As a patient At The Dental Clinics At UCSF, You Also Have The
Following Responsibilities:
1. To report to the best of your knowledge, accurate and complete
information regarding any matters pertaining to your health to
your dental provider and other health care professionals caring
for you
2. To follow the treatment plan recommended by your dental
provider (subsequent to informed consent and your
authorization to begin treatment)
3. To keep appointments
4. To accept the consequences of your own decisions and
actions, if you choose to refuse treatment or not to comply with
the instructions given by the dental provider
5. To assure that your financial obligations for your health care
are fulfilled as promptly as possible
6. To follow Dental Clinics rules and regulations affecting patient
care and conduct
Revised: Apr-11
SECTION 4 – DENTAL PATIENT BILL OF
RIGHTS AND RESPONSIBILITIES
7. To respect the rights and property of other patients and Dental
Clinics personnel, including no cell phone use in the patient
reception and treatment areas
8. To follow the UCSF smoke free policy
Revised: Apr-11
SECTION 5 – PATIENTS CONCERNS AND GRIEVANCES
I.
PURPOSE
A. The purpose of these policies and procedures is to ensure that patient
concerns, complaints/grievances are responded to and resolved in an
appropriate and timely manner, and that all appropriate steps are
taken to prevent recurrence of any such circumstance identified as the
cause of the complaint. Patients have the right to express concerns or
complaints with assurance that the submission of a complaint will not
compromise the quality of their care or future access to care.
II.
POLICIES
A. Patients shall receive written information on their patient rights prior to
receiving care at the School of Dentistry.
B. Patient inquiries, concerns and complaints shall be acted upon and
resolved expeditiously, and whenever possible, at the operational
level where patient received care.
C. The Clinic Administrative Services Office (room D1000D, telephone
number 476-1778) is responsible for the investigation and resolution
of patient complaints that have not been satisfactorily resolved at the
operational level.
D. The Clinic Administrative Services Office coordinates the activities of
all individuals involved in a complaint (see III below), and is
responsible for assuring timely and appropriate responses, and for the
establishment and maintenance of appropriate records and files of
complaints and their resolutions.
E. The Clinic Administrative Services Office maintains copies of the
Patient Inquiry/Complaint forms available for any patient wishing to
document their complaint.
F. Patients have the right to appeal any initial decisions made to resolve
their complaints.
III.
PROCEDURES
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SECTION 5 – PATIENTS CONCERNS AND GRIEVANCES
A. A patient concern or complaint is defined as any report of a
circumstance or incident received in-person, in writing, by telephone
or email.
B. The Clinic Administrative Services Office investigates and coordinates
responses to patient inquiries, concerns or complaints as defined
above.
1. Many (if not most) patient inquiries, concerns and complaints
can be resolved by administrative staff as outlined in the Staff
Guidelines for Handling Basic Patient Inquiries or Complaints.
2. Upon receipt of a complaint or grievance (not handled by
administrative line staff), either in-person, in-writing, via
telephone or email, office personnel assure the grievant that
the matter will be investigated within a specified time frame.
Reasonable efforts are made to resolve problems as soon as
possible and within 30 days.
3. Office personnel initiate a Patient Inquiry/Complaint Form when
the complaint is received, records all activities that pertain to
the complaint and forwards, when appropriate, copies of the
form to the appropriate department manager or clinic director.
Patient Inquiry/ Complaint Forms are kept on file in the Clinic
Administrative Services Office for three years.
4. Office personnel contact the appropriate department manager
or clinic director for the area from which the complaint
originated to gather the information needed to resolve the
problem and provides this individual with all available
information regarding the complaint. After discussion, Office
personnel may be able to implement actions to resolve the
problem and notify the patient or it may be more appropriate for
a manager/director to respond to the complaint.
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SECTION 5 – PATIENTS CONCERNS AND GRIEVANCES
5. Office personnel or manager/clinic director notify the patient inwriting or by telephone of the actions taken to resolve the
complaint and follows-up with the appropriate individual/s to
see that such actions actually occur.
6. Office personnel or manager/clinic director serves as the
complainant’s point of contact for future questions regarding the
complaint until there is a successful resolution.
C. In all cases, the Clinic Administrative Services Office acts as a
facilitator to ensure consistency in the application of policies regarding
patient concerns and complaints. In addition, CAS serves as a liaison
to the Risk Management and Quality Assurance coordinators to
assure that pertinent complaints are brought to their attention.
IV.
REVIEW, ANALYSIS AND REFERRAL
A. The Clinic Administrative Services Office reviews all complaints to
ascertain issues or trends that require additional attention.
B. Issues that suggest the potential for liability are discussed with the
Risk Management Coordinators.
C. Patterns or trends of specific patient complaints and risk management
issues are discussed with the appropriate administrators and
managers.
D. Patterns or trends that appear to be related to provider performance
will be referred, after response to the patient, to the Associate Dean
for Clinical Affairs and/or the Chair of the Quality Assurance
Committee.
E. The Clinic Administrative Services Office will distribute trend reports to
Dental Clinics constituencies on a periodic basis to raise awareness of
and participation in preventing or reducing future patient complaint or
risk management occurrences.
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SECTION 5 – PATIENTS CONCERNS AND GRIEVANCES
V.
COMPLAINTS ORIGINATING IN PREDOC CLINIC OR BUCHANAN
DENTAL CENTER
A. When a patient files a complaint regarding their clinical experience in
the main Predoctoral Clinic or Buchanan Dental Center, - the
information is entered into our QA database.
B. The complaint is acknowledged and the patient is informed of the
process for review by the appropriate Clinic Director. The complaint is
then routed to the appropriate Clinic Director for review and
resolution. The Director reviews and responds. Documentation of the
decision/resolution is entered into the database. (letters,
etc…attached for future reference).
C. Patients can appeal the decision and request further review when the
Clinic Director is unable to satisfactorily resolve the complaint. The
Predoctoral patient appeal is then reviewed by the QA Committee.
The decisions of this committee are final. The patient will receive a
written response within 14 days of the QA meeting.
Revised: Apr-11
SECTION 6 – PATIENT RECORDS
All patient contacts must be clearly documented in the electronic patient
record.
The patient dental record is a legal document which reflects patient history
and serves as a chronological record of patient care; as such, they are to be
maintained in an accurate, timely and legible manner. The patient dental
record consists of a medical history, examination forms, radiographs,
consultation requests, treatment records (including progress notes), written
communications with or about the patient, administrative forms and copies of
prescriptions. All patient dental records are the property of the UCSF School
of Dentistry and access is granted or released to the student for the purpose
of recording patients' treatment.
Paper Records must be returned immediately to the files at the end of each
appointment and are never to be stored in student lockers or removed from
the School of Dentistry. Please return the chart to the chart bin located
adjacent to the Clinic B Administrative Assistants. Return charts to the drop
off bin after hours.
Medical and dental information contained in patient dental records is
confidential. Patients' right to privacy concerning their medical and dental
status must be respected.
Patients have the right of access to the information contained in their records
by written request. Any request for such information, including radiographs,
should be referred to the information and registration desk on the first floor.
Patients must authorize in writing any release of information. Students must
never give the patient any portion of the permanent dental record.
Revised: Jun-11
SECTION 6 – PATIENT RECORDS
I.
RECORD ROOM
A. Policy and Procedures
1. Requested at the Front Desk Reception Area 8-5 pm
Room #: D1000
B. July 2009 the School of Dentistry ceased using paper charts. Charts are
maintained for historical information going back two years in the onsite
record room, and can be retrieved from Storage as needed beyond that
period.
C. To obtain a patient’s hardcopy of their chart it must be requested via
email, or telephone to the front desk. Chart requests will be retrieved
using a pull list and charts will be matched for scheduled COE/POE
appointments. The charts will be delivered to the 2nd front desk reception
desk area.
D. The following procedures will be necessary in order to remove a chart
from the record room or access a patient chart that is not assigned to a
student. Request the chart from the front desk or the Administrative
Assistants on the floor.
1. The staff person handling your request will verify that the
student is listed in computer as a provider.
2. Each student can have no more than ten hardcopy charts
checked out a time. If additional charts are needed, one or
more must be checked in to receive another keeping the total at
ten.
3. If a student needs to check out a patient’s chart and they are
not one of the patient’s providers, the Administrative Action
form must be signed by the clinic director to be provided access
in the Axium Electronic Record must accompany the request.
4. Authorized users in addition to students and faculty are:
a. Clinic or Financial Assistants
Revised: Jun-11
SECTION 6 – PATIENT RECORDS
b. Bonded receptionists
c. Financial billers
d. Office for Clinic Administrative Service
5. X-ray, emergency, and walk-ins patients are exceptions to the
above policy
E. As above, an Administrative Action form must accompany any exceptions
in this procedure.
F. The record room will verify computer program information and that the
provider does not have 10 charts assigned to them. This information will
be relayed to the floors by return computer message or intercom.
II.
COMMONLY ASKED QUESTIONS
A. When are charts pulled for appointed patients?
1. If a paper chart exists it will be pulled one day prior to the
appointment date if requested by the student/faculty. The chart is
unavailable to the student until the morning of the appointment
from their Administrative Clinic Coordinator.
B. If I make an appointment for my patient the night before, how do I get my
chart?
1. see item D3 above
C. If I didn't schedule a patient on the computer system or my patient
canceled and I brought in another patient, how do I get my chart?
1. see item D-3 above
III.
PATIENT CHART DROP-OFF AFTER 5:00 PM
A. At the request of students, an after-hours drop-off receptacle for patient
charts has been identified for your use. Given that the clinic floor
reception desks closed at 5:00PM, you may deposit patient charts after
this time in Clinic B Administrative Assistant desk.
B. Rather than hold on to patient charts, you now have a convenient place to
deposit the charts. Please take advantage of this opportunity to ensure
Revised: Jun-11
SECTION 6 – PATIENT RECORDS
that all charts are returned on a daily basis for proper filing in the Records
Room. It is imperative that you return patient charts on a daily basis to
guarantee their availability to all clinic constituents.
IV.
RELEASE OF HEALTH INFORMATION
A. Purpose:
1. UCSF School of Dentistry is committed to protecting patient
medical information and promoting confidentiality and security.
B. A patient’s medical record is the property of the health care provider, but
the information belongs to the patient. Patients have the following rights in
regards of their medical information:
1. Right to inspect and request a copy
2. Right to request an amendment or addendum
3. Right to an accounting of disclosures
4. Right to request restrictions
5. Right to request confidential communications
6. Right to receive a notice of privacy practices (see Notice of Privacy
Practices for details)
7. Patients have a right to obtain from UCSF School of Dentistry a
copy of their medical record in an electronic format, when
requested. If patient chooses, they can direct UCSF to transmit the
copy directly to an entity or a person
C. Procedure:
1. Patients are entitled to inspect or receive copies of the records
upon written request and payment of reasonable clerical cost.
2. Either the Medical Records Department or the School of Dentistry
front desk receiving the request, processes the written request.
3. The written request is date stamped at the time of receipt.
4. A completed and signed Authorization for Release of Information
should be present. If it is not present the patient or his/her legal
Revised: Jun-11
SECTION 6 – PATIENT RECORDS
representative will be contacted and Authorization for Release of
Information form will be obtained. (Appendix 6.IV.C.4)
5. Record Room personnel should review the Authorization for
Release of Information to make sure that it contains the following
data and in the format requested by the patient (e.g., printed,
burned onto CD) :
a. Name of the institution that is to release information
b. Name of the individual or institution that is to receive the
information
c. Patient’s full name and date of birth
d. Extent of nature of information to be released, with inclusive
dates of treatment
e. Specific date, event, or condition upon which the
authorization will expire unless revoked earlier
f. Date the authorization is signed ( Note: Date of signature
must be later than the date of information to be released)
6. The requested health information is located using both electronic
and paper record.
7. The health record is reviewed in order to safeguard and protect
information not applicable for release.
8. The requested information is copied/printed or burned onto a CD
as requested by the patient.
9. A copy of the Authorization for Release of Information and a copy
of the written request for information are
a. Recorded in the shared file folder under Y: drive under the
folder named “Records”. The original request and
authorization are scanned into the health record under
“Miscellaneous” and authenticated by the person who
processed the release.
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SECTION 6 – PATIENT RECORDS
b. The original request and authorization are attached to the
health information and are mailed to the requestor or made
available for pick up from the main Reception Desk from
8:00 am to 5:00 pm.
c. Patient requests will be processed within 14 days from
receipt of the request.
10. A charge of $20.00 per record is applied to copy medical/dental
records.
11. The date and purpose of request, name of the requestor and the
actual dates when information was released will be recorded in the
Computerized Release of Information Log by Administrative
Assistants personal. (See attachment I below)
12. Upon patient request, the UCSF School of Dentistry will restrict the
disclosure of the protected health information if the disclosure is
not otherwise required by law, to a health plan for payment or
health care operations and the PHI pertains solely to a health
service for which the patient has paid out of pocket in full.
13. A patient request for restriction should be received in writing and at
a minimum contain the following information:
a. Patient name
b. date of birth
c. Health record number
d. what protected health information should be restricted
e. signature of patient or authorized representative
f. date
g. contact information for reply
14. A patient request for restriction should be forwarded to the Health
Record/ Administrative Assistant for review and processing. A
note about the restriction will be entered in patient electronic
Revised: Jun-11
SECTION 6 – PATIENT RECORDS
record in the contact note area of the health record. The
Administrative Assistant desk staff will update this notice as
needed and the Medical Record and Billing staff will check
Release Restriction note for every release they process to carefully
check the record prior to complying with the request.
15. The patient has a right to obtain from UCSF School of Dentistry a
copy of their health record in an electronic format, when requested.
A request should be forwarded to the UCSF School of Dentistry
Medical Record Department.
16. A patient request to obtain a copy of their health record in an
electronic format should be in writing and accompanied by a
completed and signed Authorization for Release of Information
form.
17. The requested medical information is located using both electronic
and paper record.
18. The requested information is scanned and converted to PDF file
format.
19. The PDF file is recorded on a CD and mailed to the requestor or
directly to the entity or a person designated by the requestor,
provided that any such choice is clear, conspicuous and specific.
a. A charge $20 per chart is applied to scan medical records
D. Radiograph Duplications:
1. Requests should be directed to: UCSF School of Dentistry, 707
Parnassus Ave. San Francisco, CA 94143, attention: First Floor
Reception Desk. FAX: (415)476-0409.
2. Radiographs and other materials duplication fee: $20.00 per type
of item. For example, if a patient requests copies of all records,
radiographs and photographs, then patient would be charged
Revised: Jun-11
SECTION 6 – PATIENT RECORDS
$20.00 for records, $20.00 for digital radiographs /digital
photographs.
E. The University accepts: cash, checks, money orders, major credit cards
and debit cards. Checks and money orders should be made payable to:
Regents of the University of California.
Revised: Jun-11
SECTION 6 – PATIENT RECORDS
ATTACHMENT I
Computerized Release of Information Log
Medical Records Personnel
Date Records Sent
Chart Number
Patient Name
Requestor :
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SECTION 6 – PATIENT RECORDS
Checklist for Request of Electronic Record –
For patients who request an electronic copy of their chart, there will need to
be a folder on the :\ drive (for example, EHR requests) and within that
folder you will create a folder for each patient’s record. The record will
then be transferred to a CD (separate directions).
Patient Card
_____ Demographics
Print icon in Patient Card, select Adobe (PDF), select folder and name
file.
_____ Patient Contact Notes
Contact Notes icon in Patient Card, Preview report, export (envelope
icon), format – pdf, all pages, select folder and name file.
Transactions
_____ General tab
Highlight any item, right click, select Print List select Adobe (PDF),
select folder and name file.
_____ Notes tab
Highlight first note, right click, select Print List select Adobe (PDF),
select folder and name file.
EHR
_____ Medical Alerts
Right click on Medical Alerts: on Alerts tab, select Print Medical Alerts,
select Adobe (PDF), select folder and name file.
_____ Treatment History
Print icon, select Adobe PDF, Save as, select file folder and name file.
_____ Forms
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SECTION 6 – PATIENT RECORDS
Select forms set from right, select print icon, Preview button, envelope
icon, Acrobat format (PDF), all pages, select file folder and name file.
Repeat for each form set.
_____ Attachments
Select tab with number in (#), highlight the attachment, preview icon,
Save as, select file folder, name file. If saved as other than pdf
change Save as type to PDF. Repeat for each Section with a number
in (#).
_____ Perio Charting
Increase screen to full size (up arrow on right of Perio chart). Select
first date under Exams tab, printer icon, select Adobe (PDF), select
folder and name file. Repeat for each date on Exams tab.
_____ Tx Plan
Highlight first Treatment Plan on Plans tab, Patient Acceptance tab,
Contract History button, highlight contract, click View button, File drop
down, Save as, select folder and name file. Repeat for each Plan on
Plan tab.
_____ Images
‐
‐
‐
‐
‐
Make sure patient is selected in axiUm
Click the Imaging icon to get to Emago
From the File drop down menu at the top of the screen
o Select Export
 Select Export all…
Destination folder :
o Select the patient’s folder, can name the new folder. The
images will be saved as a folder.
Click Selection button. The following window displays:
Revised: Jun-11
SECTION 6 – PATIENT RECORDS
‐
‐
‐
o Automatically defaults to all. Can uncheck the images not
needed and select the time period, but will usually need all.
The images will display in the Selected images: window. They will
not be mounted.
Always save the file as a JPEG.
Click OK button to save the images in the folder.
After all the reports/images have been downloaded the patient folder can be
moved to a CD. Once this has been completed the individual patient
folder can be deleted at any time.
V.
DIGITAL RECORDS PROTOCOL
A. INTAKE- Patients may request inclusion of digital files (including
radiographs, photos and print) from outside (non-UCSF) sources into their
UCSF S/D electronic health record (eHR). This protocol provides a step-bystep process and establishes a non-refundable fee for this record
supplementation process. Specifically regarding digital radiographs
contained on non-viewable media, i.e. CD/DVD, if some or all of the images
submitted do not meet diagnostic-quality standards, supplemental
radiographs may be necessary and radiography fees are charged to the
patient.
B. SECURITY- For security reasons, we will limit incoming (uploading) digital
files, including radiographs and photographs to high-quality photo paper,
CD/DVD and email formats.
Revised: Jun-11
SECTION 6 – PATIENT RECORDS
1.
CD, DVD, print and photo attachments
a.
Patients must submit image media to reception staff who
carries out the following:
i.
Completes the RADIOLOGY REFERRAL, REQUEST
AND RECHARGE FORM
1.
Procedure Description and Codes:
a.
Digital Image Upload, CD/DVD - Code:
D03001
b.
Digital Image Intake, Film/Photo Scan -
Code: D03003
ii.
b.
Collect fee: $20
Staff forwards request and media to Oral Radiology (O/R)
for import, mounting and charge-out (completion)
c.
Original media returned to first-floor reception area for
temporary storage until retrieved by the patient
d.
“Sticky Note” posted in Axium to notify patient
e.
After media returned to patient, make entry into “Contact
Notes” documenting return
2.
Email attachments
a.
Direct all requests to send digital images to S/D via email to
reception or telephone bay. Staff carries out the following:
i.
Completes RADIOLOGY REFERRAL, REQUEST AND
RECHARGE FORM
ii.
Collect/process payment - $20
iii.
Provide patient instructions for sending digital images via
email (form)
1.
Patient must include the following identification in
their e-message to O/R:
a.
Patients’ full name
Revised: Jun-11
SECTION 6 – PATIENT RECORDS
2.
b.
Chart number
c.
Date of Birth
Patients must send email with digital image
attachment file to: [email protected].
iv.
b.
Forward request to Oral Radiology after fee received
Oral Radiology staff will use identifying information provided
by patient’s email to confirm request, upload and mount images
c.
Charge-out procedure (complete)
C. DUPLICATION - Patients may request duplication of their electronic health
record (EHR), including notes, radiographs and photos. This protocol
provides a step-by-step process and establishes a non-refundable fee to
offset administrative costs. Delivery of duplicated records includes in-person
pickup, domestic USPS delivery or email.
1.
Direct all requests for records duplication to the reception or phonebay
staff. The staff carries out the following:
a.
Complete Authorization for Release of Dental Records
Form and obtain patient’s signature
b.
Complete RADIOLOGY REFERRAL, REQUEST AND
RECHARGE FORM when patient requests duplication of digital
images (radiographs or photos)
i.
D03005 - Copy of Digital Images/records - Print
ii.
D03006 - Copy of Digital Images/records - Email
iii.
D03007 - Copy of Digital Images/records - CD
c.
Forward request to Oral Radiology after fee received
d.
Collect fee ($20)
e.
Duplicates EHR notes when patient requests chart/notes
duplication only
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SECTION 6 – PATIENT RECORDS
2.
Oral Radiology staff receives RADIOLOGY REFERRAL, REQUEST
AND RECHARGE FORM for digital image duplication and carries out
the following:
a.
Export images from Axium/Emago and prints on high-quality
photo paper, burns CD or emails images to patient
i.
Attach hard-copies to RADIOLOGY REFERRAL,
REQUEST AND RECHARGE FORM and place in
reception in-box for pickup or mail to patient or designate
(DDS)
ii.
Email to patients must adhere to University HIPAA
guidelines: Subject Line: ePHI: Digital Radiographs
b.
Charge-out procedure as complete.
Revised: Jun-11
SECTION 7– FINANCIAL
I.
INTRODUCTION FOR PREDOCTORAL STUDENTS
A.
All patients receive a Financial Policy Statement upon registration. It is the
responsibility of the student-doctor to review the document with the patient to
insure the patient understands and accepts the terms of the policy
statement. Providers and patients are encouraged to discuss financial
questions with the Financial Assistant or the Administrative Clinic
Coordinators. Clinic Directors and /or the Clinic Manager (MSO) can provide
clarification or interpretation of the financial policies when issues that are
more complex arise.
B.
The Predoctoral Clinic is a cash or “pay as you go” comprehensive dental
care clinic. It is the responsibility of each student-doctor to maintain a
balance of production and financial arrangements such that each of their
comprehensive care patient’s account balance is zero or has an account
credit for in-process dental procedures. Patients with an outstanding
balance, reflects poor patient management and requires corrective
intervention by clinic administration.
II.
PRODUCTION EQUIVALENT AMOUNTS
A.
Production EQ Amounts – are the gross charges entered at charge entry.
Production is a valuable metric for quantifying the learning experiences to
which each student-doctor is exposed. This report includes all procedures
properly entered into AxiUm, approved by the attending faculty member
supervising treatment and allocated to a patient’s account. This report does
not reflect discounts or no-charged treatments. NIS generates production
reports and distributes them to the appropriate course directors on a
quarterly basis.
SECTION 7– FINANCIAL
III.
CHARGE ENTRY & MISSING CHARGES REPORT
A.
The School of Dentistry requires that every patient visit must have an
accompanying transaction entered in Axium within seven days of treatment.
B.
All charge entries must have diagnostic and prognostic codes entered
C.
All entries must receive attending-faculty authorization (e-signature)
D.
Providers (Students/Faculty/Residents) are required to clear their missing
transactions using this report on a weekly basis and any charges missing
greater than 45 days will result in a student registration hold.
E.
The Clinic Manager/Designee will monitor and review the outstanding
missing charges reports on a monthly basis to ensure prompt resolution of
missing charges.
IV.
UNAPPROVED TREATMENT
A.
Unapproved treatment is defined as procedure/s charged out without
authorization from an attending faculty. Students cannot provide dental
treatment without faculty approval.
B.
NIS runs a quarterly report of unapproved treatment and provides this
information to the Student Services Department. Students who fail to clear
outstanding unapproved treatment are placed on registration hold.
V.
REMOVE UNAPPROVED TREATMENT
A.
To remove Unapproved Treatment, student-doctor must have attending
faculty approve (provide e-signature) each in-process and completed
procedure that is without authorization. To clear the registration hold student
should present the completed report to Office for Clinic Administrative
Services (OCS) Room D1000. The OCS staff will contact Student Services to
remove the registration hold after verification that you have cleared the
outstanding issues.
SECTION 7– FINANCIAL
B.
Present completed report to Office for Clinic Administrative Services (OCS),
Dave Gonzalez. OCS will contact Burton Ober to remove registration holds.
VI.
ACCOUNTS RECEIVABLE (A/R)
A.
Accounts Receivable reflects money owed to the School for services
delivered to the patients whether completed or in-process. Accounts
Receivable is a valuable metric for quantifying a student’s patient
management skills and compliance to clinic policies and procedures. NIS
generates AR reports and distributes them to the appropriate course and
clinic directors on a quarterly basis.
B.
Students are responsible for maintaining their patients’ collective AR below
$500.
C.
Student-doctors with a collective AR exceeding $500, as reported by NIS,
are barred from registration for the upcoming quarter.
D.
To remove excess AR, student-doctor must facilitate an effective financial
arrangement that eliminates their patient’s outstanding balance.
E.
Patients with outstanding balances are placed on discontinued status until
their outstanding balance is zero.
F.
Patients may not make future appointments in the comprehensive care clinic
if their account is in arrears.
VII.
A/R DOCUMENTATION
A.
The School of Dentistry billers are expected to review and document
outstanding accounts on a regular basis. Clinic Managers will review the
A/R balances using the Aging Report on a monthly basis. This monthly
review includes all open accounts including credit balances. The review will
be documented and retained for six months.
B.
The Patient Billing Unit will review and note status of accounts in the process
of reviewing patient accounts.
SECTION 7– FINANCIAL
VIII.
STUDENT APPOINTMENT ENTRY
A.
All patient visits must be entered into Axium and can be entered by the
Clinical Assistants (ACC or AAII) or the students directly. The exception to
this policy is for the Pros Bay which requires entry into the Axium schedule
by the Clinic Assistants.
B.
Students are responsible for clear descriptions of the next planned treatment
in the comments area of the appointment information.
C.
Patients must check-in at front desk prior to seating
D.
Patients seated in cubicles without proper entry into Axium and check-in at
the front desk will be dismissed from the clinic
E.
Students seating or treating patients not properly entered into Axium and
checked-in are subject to immediate suspension from the clinic
F.
Cubicles are subject to reassignment if student-doctor and/or patient fail to
follow appointment protocols.
G.
Failure to schedule patients properly, improper charge entry and failure to
obtain faculty approval are unprofessional conduct for failure to follow clinic
policies and procedures. Such violations will result in clinic suspension,
barring from registration and possible dismissal from the School of Dentistry.
IX.
ELECTRONIC CLAIM PROCESSING
A.
The School of Dentistry requires that all clearinghouse rejection reports are
be cleared within 14 days of receipt of the report. Items that are not cleared
within the 14 days must be documented in Axium.
X.
ALLOCATIONS FROM ANOTHER CLINIC
A.
The School of Dentistry NIS Department is responsible for sending the
Allocations from Another Clinic to the Clinic Managers/Designees on a
monthly basis. The report will be reviewed monthly and documented by both
the billing staff and the Clinic Manager.
SECTION 7– FINANCIAL
XI.
UNALLOCATED PAYMENT ALLOCATION/REPORTING
A.
The School of Dentistry NIS Department is responsible for sending the
Unallocated Reports to the billers/Clinic Managers/designees on a weekly
basis. The staff are also provided access to run the report Ad Hoc and
expected to work the report daily. The Unallocated report is to be reviewed
monthly both the billing staff and the Clinic Manager.
The School of Dentistry Predoctoral Clinic will clear outstanding unallocated
payments dating prior to 2009 and refund or credit back (CBA adjustment
code) to the patient's account the balance for future use in the clinics. In the
case where refunds are not possible, the following process is applied:
XII.
PROCESS FOR UNALLOCATED REVIEW
A. Search and apply to patients in the Predoctoral Clinic Banks Only
1.
Post a credit (CBA) code
2.
Post a note in the transaction that there is a credit available in the
account to be applied to future work or refunded by request
3.
Post a pop up note that if the patient is selected by anyone at
anytime in the future the note would indicate the credit is
available
XIII.
ADJUSTMENT CODES
Clinic Directors and Predoctoral Department Managers have the authority to
authorize an adjustment on a patient account. Documentation of the reason for the
adjustment must be evident in the patient record and in the transaction notes. The
actual entry is posted by based on the Axium User Authority level.
A. In the Predoctoral Clinic, the adjustments are posted by the Financial
Assistants.
B. Authorization of Adjustments
SECTION 7– FINANCIAL
Discounts
C. Professional Discounts and courtesy discounts are not used in the
Predoctoral Clinic.
D. Student Family Discounts (CODE SFD) apply only to the UCSF SOD student
and their spouse. The maximum discount is 50% of the co-pay.
E. The School of Dentistry Axium adjustment code list has been consolidated
and defined. (See Attachment IV) as of 08/31/2010
F. The active adjustment code list is attached for the SOD Axium and Winoms
Billing systems.
XIV. REFUNDS
A. The School of Dentistry will implement a policy whereby patient refunds are
reviewed by the Clinic Manager/MSO regardless of the amount of the refund.
B. Payments made by check or cash are refunded using the UCSF Form 5
Check request with appropriate signature approval.
C. Payments made by credit card are processed as a credit back to the same
credit card used whenever possible. A note is entered into the Axium
transaction notes indicating who authorized the refund and the date.
D. Axium Refund Reports will be generated by the billing unit and reconciled in
the monthly reconciliation against the excel log and Weblinks report.
XV.
RECONCILIATION ACTIVITIES
A. The School of Dentistry Clinic Managers will verify that a monthly
reconciliation of the Axium reports for the clinic includes the reconciliation of
payments, refunds and adjustments posted. The Monthly Reconciliation of
Axium to Ledger Guidelines Format (Attachment III) and the SAS 112
General Ledger Verification Forms will be utilized in that process.
B. The School of Dentistry Clinics Managers will utilize the SAS 112 General
Ledger verification form and the suggested formula for reconciliation of the
Axium entries at the close each month in Attachment III.
SECTION 7– FINANCIAL
XVI.
STAFF TRAINING
A. The School of Dentistry Patient Billing Meetings will provide
annual training and review of UC Cash Handling, Axium
Specific training and the policy and procedures covered in this
policy. This annual training should include overall Accounts
Reconciliation and specific documentation requirements as
stated in this manual.
Definitions
Accounts Receivable
Money owed to the School for services completed or in-process.
Axium
This is the software of choice for the School of Dentistry and is the method of used for
scheduling, billing, and tracking patient and academic activities. The system is patient
based with one account for a patient who may be seen in multiple clinics
simultaneously.
Missing Charges Report
The Missing Charges Report reflects that a patient was scheduled to come into the
clinic for a visit and charge was not yet posted to the account for that date and provider.
Production Equivalent Amounts
Production EQ Amounts are the gross charges entered at charge entry. Production is a
valuable metric for quantifying the learning experiences to which each student-doctor is
exposed
Unallocated Payments
Unallocated payments are patient payments for unapproved treatment. As such, the
unspecified payment remains in the patient’s account until allocated to an approved
SECTION 7– FINANCIAL
treatment. Unallocated payments have the effect of a non-specific credit, which reduces
the patient’s account balance.
Unapproved Treatment
Unapproved treatment is defined as procedure/s charged out without authorization by
an attending faculty.
Winoms is the software of choice for the Oral & Maxillofacial Surgery Department
Clinics scheduling and billing of both dental and medical procedures.
SECTION 7– FINANCIAL
Attachment I
DENTAL INSURANCE HOLDERS:
The Buchanan Dental Center accepts most private dental insurance. If the patient’s
insurance company provides them with a list of dentists on their plan, please make sure
the Buchanan Dental Center appears on the list. Patients can call the front desk if they
have questions. We will be happy to verify coverage for them.
The patient’s estimated co-payment is due at the time of service. We will bill the
insurance company for the patients. Unfortunately, payment plans are not available for
the patient’s estimated portion as all portions are only estimates.
While estimates are based on our best knowledge of the patient’s insurance plan,
estimates are not a guarantee of payment. Exact payment cannot be determined until a
claim has been submitted and processed by the patient’s insurance company.
Note: If for any reason, the patient’s insurance company denies payment; they
are responsible for payment of the entire balance.
Estimating: The financial advisor will review the treatment plan with the patient and
provide an estimate of their insurance portion. We encourage a predetermination of benefits for major treatment such as bridges, crowns &
dentures. We will submit any necessary paperwork for the patient.
SECTION 7– FINANCIAL
Attachment II
MEDI-CAL OR DENTI-CAL Eligibility
I. The State of California has eliminated the Adult (21 years and over) Denti-Cal
program effective July 1st. The UCSF School of Dentistry is offering a reduced fee
schedule for patients who are eligible for Medi-Cal.
II. Patients must present proof of Medi-Cal eligibility on the date of the appointment.
III. Patients will be asked to pay the reduced fees on the day of service.
IV. Payment arrangements are not available for reduced fees.
V. No discounts of any kind will be offered on reduced rates.
SECTION 7– FINANCIAL
Attachment III
Monthly Reconciliation of Axium to Ledger
Guidelines
Once the month closes in Weblinks, the reconciliation of that month can be done. The
amount that shows in the General Ledger should match to the amount shown in Axium
for the month, making several adjustments to account for monies that are recorded in
the G/L but not Axium and vice versa. Below is a basic worksheet to assist in this.
$0.00
$0.00
G/L Balance (balance from
Weblinks for the month you are
reconciling)
Less: previous months receipts
in current month ledger (this is
usually the deposit for the last
day of the month)
Add: This months deposits not
recorded in G/L
Add: Returned checks
Less: Credit Card fees
$0.00
$0.00
$0.00
calculation
of above
Adjusted general ledger ending
amount
balance
Total from Axium (Total amount
$0.00 collected by clinic in Axium)
Difference (Should always come
$0.00 to a $0.00 balance)
SECTION 7– FINANCIAL
Attachment IV
Adjustment Code Review and Description ( August
2010 SOD Billing Meeting)
revised
November
22, 2010
Code
Description
Where
Reason:
BDW
Bad Debt write off
BRC
Bridge Coupon Code
Predoc
Apply bridge discounts for student/patients regulary
BWO
Bankruptcy W/O
Predoc
When notified by the Notice of Bankruptscy
BROKEN
Broken appt
Predoc
Write off of a broken appt per instructions
CBA
Credit Balance Adj
Predoc
Used to debit out a unallocated credit - to clear acct - leaving credit for future use instead of refund
CBF
Credit Balance Refund
Predoc
Used to debit out an unallocated credit - to clear account and refund money to the patient
CCCBF
Refunded directly by Ccard
Predoc
Used to credit back to a credit card when it was used to pay for the services. Must use exact card.
CRA
Credit Adjustment
Predoc
Used to credit when no other code is suitable.
COF
Collector Fee
Predoc
Adjustment that debits the account per the Collection Agency fees and Explanation of payment
CCA
Credit Card Adjustment
Predoc
Debit Adjustment to payments when credit cards charges are disputed and charged back.
CRA
Credit Adjustment
CWO
Cambra Write off
Predoc
Credit adjustment used to clear Denti-cal charges for CAMBRA which are not covered by provided per CAMBRA - applies only to Denti-Cal patients
DBA
Debit Adjustment
Predoc
Debit adjustment used to reverse a credit that is not covered by a specific debit code
DEC
Patient Deceased
Predoc
Debit adjustment used once notified that the patient is deceased.
DFB
Deferred Balance
Predoc
Debit adjustment used to apply to payment to charges converted in Axium and are no longer available for allocation in normal manner
DISC
Discount Adjustment
DWO
Denti-Cal Write of
Predoc
Credit adjustment used to clear Denti-cal charges - applies only to Denti-Cal patients
ECC
Error Correction Chg (CR)
Predoc
Credit adjustment applied to charges when an incorrect code or charge was applied to the account
To be avoided if possible, a general ad
ECD
Error Correction Chg (DB)
Predoc
Debit adjustment applied to charges when an incorrect code or charge was applied to the account
HFAM
Healthy Families Write Off
Peds
Credit adjustment for Healthy Family patients
HKIDS
Healthy Kids Write Off
Peds
credit adjustment for Healthy Kids patients
IAC
Insurance Adjustment (CR)
Predoc
Credit adjustment applied to charges
IAD
Insurance Adjustment (CR)
Predoc
Debit adjustment applied to charges
SECTION 7– FINANCIAL
IBA
Insurance Debit Bal Adj
Predoc
Debit adjustment applied to insurance
INC
Increase Charges
Predoc
Debit adjustment increasing charges - comments are made in the description to document
INCOLL
In Houose Collections
Predoc
Credit adjustment used to zero outstanding balance and indicate Collection status (below $100 - does not go to collection)
INR
Insurance Refund
Predoc
Debit adjustment to indicate a refund to the insurance for overpayment or error in payment
IWO
Insurance Write Off
Predoc
Credit adjustment to charges that is a result of an Insurance EOB or agreeement with the party ( NON Delta) See WRO - DD for Delta Specific
JPAY
Journal Payment
Predoc
Credit to charges ( used to allocate payment transferred to another clini ) combined with either JTF or JTT for cr /db to payment & journal id in descript
JTF
Journal Transfer -DBT
Predoc
Debit adjustment to payments transferred via Journal
MWO
Medicare Write Off
Stoma
Credit adjustment to charges per Medicare Fee Schedule
NO/Ch
No Charge/Clinic Directors
Predoc
Credit adjustment to charges that are a result of Clinical Directors - (Often to prevent Risk Management complications)
PRA
Professional Discount
School wide
Credit adjustment to the charges that are approved and documented per the Clinic policy for such discounts
PTT
Payment Transfer (DB)
Predoc
Debit adjustment decreasing credit balance on one fund / authorized to be applied to another account per the patient/documented in description
PTTC
Payment Transfer (CR)
Predoc
Credit adjustment to charges as a result of funds transferred from another account
RCF
Returned Check Fee ( DB)
Predoc
Debit charge to patient for fee associated with returned checks used in conjunction with RCK to assess bank fees to the patients
RCK
Returned Check (DB)
Predoc
Debit charge to patient for amt of returned check
RMGT
Risk Management Adj ( CR)
School wide
Credit adjustment to charges as a result of Risk Management Status
RWJA
Robert Wood Johnson Adj
School wide
Credit to charges per the agreement with the Robert Wood Johnson Grant
RPMT
Reverse Payment (DB)
Predoc
Debit adjustmet to payments to reverse credit of payment
SBW
Small Balance Write Off
Predoc
Credit adjustment to charges to write off uncollectible small balance ( less than $10)
SFD
Student Family Discount
Predoc
Credit adjustment to charges discount immediate family discount (Spouse)
TAD
Transfer Balance Applied Deductible
Predoc
Credit adjustment to charges based on Explanation of Benefits -
TB-2IN
Trsf Bal to Second Ins Carrier
Predoc
Debit adjustment to charges in or der to bill secondary insurance carrier
TBD
Transfer Balance DB
Predoc
Debit adjustment to charges
TCO
Transfer to Collections
Predoc
Credit adjustment to charges indicating the account has been forwarded to collection
TEL
Transfer Balance - Exceeds Limits
Predoc
Credit adjustment to charges moving balance to patient
TIP
Predoc
Credit to charges to transfer balance to patient column
TNC
Transfer Balance - Ins Paid Pt.
Transfer Balance - Service not
covered
Predoc
Credit adjustment to charges to transfer balance to patient column
TOV
Transfer Balance - over max
Predoc
Credit adjustment to charges to transfer balance to patient column
TPN
Transfer balance - pt not eligible (CR)
SECTION 7– FINANCIAL
UWO
Predoc
Credit adjustment to charges - uncollectible and not deemed feasible for Collection Status
VOU
Uncollectible Claims - Write Off
Student's Competency Voucher credit
Predoc
Credit adjustment to charges in order to attract procedures for students
WRO
Write off
Predoc
Credit adjustment to charges … should include description in adjustment line when nothing else fits
WRO-DD
Write off - Delta Dental
Predoc
Credit adjustment to charges per the Participating Delta Fee Schedule
BAW
Bay Area Women's Center Adj
Peds
Credit adjustment for patients at the Bay Area Women's School in the Tenderloin.
CAD
Cash Discount
Peds/Ortho
Credit adjustment to patients that pay treatment cost in full at time of service, treatment only higher then $300.00
CCW
CCS Write Off
Peds/Ortho
Credit adjustment for CCS patients
JTT
Journal Transfer - credit
Peds/Ortho
Credit adjustment for money transferred to clinic from a non Axium clinic
PPLN2
Payment Plan Transfer
Peds/Ortho
Adjustment used to create a payment plan on a portion on treatment
WRO-PL
Write off Priniciple Life
Credit adjustment per the agreement between UCSF and the usual and customary fee
SECTION 7– FINANCIAL
Attachment V
Adjustment Codes per Axium
11/2010
Code
Description
Type
Apply To:
Affect Bank
Deposit
Full Payment
Reversal
Inactive
BDW
BRC
BROKEN
BWO
CAD
Bad Debt Write Off
Bridge Coupon
Broken Appt Write Off
Bankruptcy Write-Off
Cash Discount
Credit Balance
Adjustment
Credit Balance Refund
Credit Card Adjustment
Refunded directly to pts
CCard
Collector Fee
Credit Adjustment
CAMBRA Write-off
Debit Adjustment
Pt Deceased
Deferred Balance
Discount Adjustment
DentiCal Write-Off
Credit(-)
Credit(-)
Credit(-)
Credit(-)
Credit(-)
Charges
Charges
Charges
Charges
Charges
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Debit(+)
Debit(+)
Debit(+)
Payments
Payments
Payments
No
No
No
No
No
Yes
No
No
No
Debit(+)
Debit(+)
Credit(-)
Credit(-)
Debit(+)
Credit(-)
Debit(+)
Credit(-)
Credit(-)
Payments
Payments
Charges
Charges
Payments
Charges
Payments
Charges
Charges
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CBA
CBF
CCA
CCCBF
COF
CRA
CWO
DBA
DEC
DFB
DISC
DWO
SECTION 7– FINANCIAL
ECC
ECD
HFAM
HKIDS
IAC
IAD
IBA
INC
INCOLL
INR
IWO
JPAY
JTF
MWO
NO/CH
PRA
PTR
PTT
PTTC
RCF
RCK
RMGT
RPMT
RWJA
Error Correction Chg
(CR)
Credit(-)
Error Correction Charge
(DB)
Debit(+)
Healthy Families Write
Off
Credit(-)
Healthy Kids Write Off
Credit(-)
Insurance Adj.(CR)
Credit(-)
Insurance Adj. (DB)
Debit(+)
Insurance Debit Bal Adj
Credit(-)
Increase Charges
Debit(+)
In-House Collections
Credit(-)
Insurance Refund
Debit(+)
Insurance Write-Off
Credit(-)
Journal Payment
Credit(-)
Journal Transfer -Debit
Debit(+)
Medicare Write Off
Credit(-)
No charge Cli Diretors
req
Credit(-)
Professional Allowance
Credit(-)
Patient Refund
Debit(+)
Payment Transfer - Debit Debit(+)
Payment Transfer Credit
Credit(-)
Returned Check Fee
Debit(+)
Returned Check
Debit(+)
Risk Management Adj
(Cr)
Credit(-)
Reversal of Payment
Debit(+)
Robert Wood Johnson
Credit(-)
Charges
No
No
No
Payments
No
No
No
Charges
Charges
Charges
Charges
Payments
Payments
Charges
Payments
Charges
Charges
Payments
Charges
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Charges
Charges
Payments
Payments
No
No
No
No
No
No
No
No
No
No
No
No
Charges
Payments
Payments
No
No
No
No
No
Yes
No
No
No
Charges
Payments
Charges
No
No
No
No
Yes
No
No
No
No
SECTION 7– FINANCIAL
Adj
SBW
SFD
SRD
TAD
TB-2IN
TBD
TCO
TEL
TIP
TNC
TOV
TPN
UWO
VOU
WRO
WRO-DD
WRO-PL
Small Balance Write Off
Student/Imm Family
Discount
Senior Discount
Transfer bal - apply to
deduct
Trf Bal to Second Ins
Carrier
Transfer Balance Debit
Transfer to Collections
Transfer Bal - Exceed
limits
Transfer Balance - Ins
Paid Pt
Transfer Bal Serv not
covered
Transfer Balance - Over
Max
Transfer bal - Pt not
eligible
Uncollectable Claim Write Off
Student's Competency
Voucher
Write Off
Write off Delta Dental
Write Off Principal Life
Credit(-)
Charges
No
No
No
Credit(-)
Credit(-)
Charges
Charges
No
No
No
No
No
No
Credit(-)
Charges
No
No
No
Debit(+)
Credit(-)
Credit(-)
Charges
Charges
Charges
No
No
No
No
No
No
No
No
No
Credit(-)
Charges
No
No
No
Credit(-)
Charges
No
No
No
Credit(-)
Charges
No
No
No
Credit(-)
Charges
No
No
No
Credit(-)
Charges
No
No
No
Credit(-)
Charges
No
No
No
Credit(-)
Credit(-)
Credit(-)
Credit(-)
Charges
Charges
Charges
Charges
No
No
No
No
No
No
No
No
No
No
No
No
SECTION 8 – EMERGENCY PROCEDURES
I.
MEDICAL EMERGENCIES
YOU ARE RESPONSIBLE FOR THE SAFETY OF YOUR PATIENTS
DURING EMERGENCIES
A.
For Non-Life Threatening Medical Emergencies
a. In an emergency situation with a patient, call a faculty member
immediately but do not leave the patient alone. The instructor
will assist in managing the emergency situation and will decide
if a physician or transport of the patient is required. Do not
leave the patient unattended.
2. Provide emergency care. Bring the clinic’s blue emergency cart
to the emergency location, provide emergency care, and
administer oxygen if indicated. Emergency carts, equipped with
OXYGEN, EMERGENCY DRUGS, AND SUPPLIES, ARE
LOCATED IN EACH CLINIC NEAR THE DISPENSARIES. All
faculty, students, and staff must familiarize themselves with
these carts and their locations.
3. If needed, summon assistance from the Oral Surgery Clinic
who will respond if they are available. If an ambulance is
needed to transport the patient to the Hospital Emergency
Room, Call 9-911 (Campus Police) and request patient
transport. An ambulance from The American Medical Response
(AMR) will be dispatched to the dental clinic by the campus
police. If AMR cannot respond, AMR will contact the City and
County Emergency Medical Service (EMS).
4. If professional medical advice is needed, call the UCSF
Emergency Department Hotline 353-1238 for advice.
B. For Life-Threatening Medical Emergencies (Code Blue)
1. For life threatening medical emergencies at the Parnassus
Campus, Call 9-911 (Campus Police), and state that there is
Revised: Apr-11
SECTION 8 – EMERGENCY PROCEDURES
a code blue situation and give the exact location of the
emergency (e.g. School of Dentistry Clinics Building, 707
Parnassus Ave. 2nd floor, A Clinic). The operator will page
either the UCSF Code Blue Team or outside paramedics to
respond to the Code Blue situation. The police will also
respond and an ambulance for transport will be summoned.
Code Blue coverage is available 24 hours/day, 7 days per
week. It will take the Code Blue Team or Paramedics
approximately 7-10 minutes to respond.
2. Code Blue procedures are posted adjacent to the clinic
telephones and Emergency Carts. A red phone is located at
each reception area for emergencies.
3. The student is expected to provide immediate basic life
support with the assistance of the supervising faculty
member. However, the ultimate management of the
emergency is the responsibility of the supervising faculty
member until further professional assistance arrives.
4. Bring the Clinic blue medical emergency cart to the
emergency site for use by dental personnel and bring the
Hospital Code Blue cart from the 2nd floor (SW corner of
Clinic A) for use by the Code Blue Team.
5. Request the Automated External Defibrillator (AED) to be
brought to the site from the Dispensary.
6. If possible, call the Reception Desk (Extension 6-1244) and
request overhead loudspeaker Code Blue announcement to
give the location of the emergency. Position a person at the
1st and 4th floor building entrances and at elevator lobby of
floor where emergency is located to direct the Code Blue
Team or paramedics.
Revised: Apr-11
SECTION 8 – EMERGENCY PROCEDURES
C. Delegate Dental Students:
1. 1-Bring blue medical emergency cart
2. 1-Bring Hospital Code Blue (Crash) cart
3. 2-Lead other patients out of area
4. 1-At floor of emergency elevator
5. 1-At street entrance
6. 1-At 4th floor entrance
7. 1-treating dental student with patient
II.
EMERGENCY CART COMPONENTS/SUPPLIES
A. Portable Suction System (oxygen or battery powered)
1. Tonsil suction
B. Oxygen Delivery System
1. Adult Oxygen Mask (passive oxygen delivery) 4-6 L/M
2. Nasal Cannula (passive oxygen delivery) 4-6 L/M
3. Demand Valve Resuscitator (positive pressure oxygen
delivery)
4. Ambu-Bag (positive pressure oxygen delivery)
C. Nasal Pharyngeal Airways
D. Oral Pharyngeal Airways
E. Stethoscope and Blood Pressure Cuff
F. I.V. needles, solutions, and supplies
G. Glucose Meter
H. Drugs
1. Epinephrine (EpiPen 0.3 mg ) 3 injectors (e.g. for
anaphylactic shock/acute allergic reaction)
2. Glucose tablets (5 gm Dextrose per tablet) (oral sugar for
hypoglycemic patient)
3. 50% Dextrose Solution 25 gms (0.5 gm/ml) for IV injection
for unconscious hypoglycemic patient
Revised: Apr-11
SECTION 8 – EMERGENCY PROCEDURES
4. Injectable Benadryl 50 mg/ml (for mild allergic reaction)
5. Benadryl 50 mg tablets (for mild allergic reaction)
6. Spirits of ammonia (for syncope)
7. Nitrolingual Spray (0.4 mg/spray) for angina pectoris
8. Solu-Cortef (hydrocortisone for injection 100 mg) for
adrenocortical insufficiency
9. Albuterol bronchodilator inhaler for acute asthmatic attack
10. IV solution 500 ml bag sodium chloride 0.9 % with glucose 5
% (2 bags)
I. Automated External Defibrillator (AED) (in dispensary) for cardiac
arrest due to ventricular fibrillation
III.
CARDIOPULMONARY RESUSCITATION (CPR) REQUIREMENT
A. Cardiopulmonary Resuscitation skills are needed for students to
provide appropriate support to patients or the general public
during a life threatening medical emergency. Students will be
required to obtain CPR certification or recertification training by a
specified time period to be eligible for patient care privileges in the
clinics (either as a provider or assistant):
1. First Year Dental Students-by the end of the fall session
2. International Dental III Students-by the end of the summer
quarter
3. Dental III Students-by the end of the fall quarter
B. Clinic Administration will be responsible for contacting the campus
CPR Center or other training agency to verify the students that
have successfully completed the CPR training sessions by the
specified time periods. Those students that have not completed
the CPR training sessions will be notified that they are not eligible
for patient care until the clinic requirement has been successfully
met.
Revised: Apr-11
SECTION 8 – EMERGENCY PROCEDURES
IV.
INJURIES AND ACCIDENTS
A. Management of an Unusual Occurrence: An “unusual occurrence”
is defined as a situation, other than immediate life support, which
happens while a patient is being treated in the clinic. An example
would be a patient swallowing a rubber dam clamp or aspirating
an item into the airway. When a situation of this type arises, call a
faculty member. If further attention is needed, the student should
take the patient to the Long Hospital emergency room and assure
that the patient is evaluated and treated as necessary. A School
of Dentistry Confidential Incident Report Form (Appendix 8.IV.A)
must be properly filled in, signed and returned to the Office for
Clinical Services within 24 hours.
B. Management of injuries to students, staff and faculty: after first aid
or emergency care as indicated is provided, an Injury Report
Form must be filed with the Office for Clinical Services within 24
hours.
C. Procedures for needlesticks, other punctures, or cuts involving
potentially contaminated materials can be found in Section 10 Infection Control Protocols under Heading H - Other Infection
Control Procedures. PERSONNEL SHOULD TREAT ALL
NEEDLESTICK EXPOSURES AS POTENTIALLY INFECTIOUS.
Any incident involving blood contact on a cut, or abraded skin or
mucous membrane should also be treated as potentially
infectious.
D. When an exposure of any kind has occurred, personnel should
seek first aid and emergency treatment in accordance with the
posted needlestick protocol (see posted cards in the predoctoral
clinic and needlestick protocol in Section 10).
V.
PROTOCOL FOR OBTAINING MATERIAL SAFETY DATA SHEETS
Revised: Apr-11
SECTION 8 – EMERGENCY PROCEDURES
A. The procedure for obtaining Material Safety Data Sheets (MSDS)
is described below. This information will now be obtained through
the Internet instead of by fax.
1. Should you wish or need to obtain MSDS information during
non-working hours or on your own, you may access the
MSDS information via the Internet by following these
directions:
a. From a designated computer in your building,
connect to your Internet system
b. These computers will be book-marked directly to the
MSDS resources. Look under "bookmarks" for MSDS
and connect
c. If there is no MSDS book-marked in your system, or
if you are not using one of the designated computers
listed, go to the UCSF home page. (You will
automatically be connected to the UCSF home page
when you connect to your Internet from a UC
computer). Connect to items under the letter E
d. Connect to " Environmental Health and Safety"
e. Connect to "MSDS”
f. Suggested web sites are Vermont SIRI and Cornell
University. These are the sites which our EH&S
department frequently uses to obtain MSDS
information
g. Follow the instructions at these sites, preferably by
using the chemical name in the search. If the
chemical name is not known, then the product name
may be used
Revised: Apr-11
SECTION 8 – EMERGENCY PROCEDURES
B. The EH&S department does maintain a file of hard copy MSDS
sheets, however, they recommend using the Internet as the
information is more easily accessible
C. The following sites will have computers available for use in
obtaining MSDS information:
1. Parnassus Clinics, room D2209
2. Stomatology/Oral Medicine, S-612
3. Buchanan Dental Center, 100 Buchanan Street
4. Oral Surgery, room S-738
5. Center for Craniofacial Anomalies, room C747
6. Periodontology Faculty Practice c/o C-628J
D. Should you wish to obtain information concerning MSDS sheets
and have difficulty using the Internet or finding the desired
information during normal working hours, you may call EH&S at
476-1300to obtain any needed information
E. EH&S maintains an EMERGENCY response service 24 hours a
day, which may be reached by calling 9-911from a UC phone.
You may describe the nature of your call and the emergency
operator will direct your call to an on-call EH&S representative.
This would most often be used for chemical spills, or industrial
accidents. PLEASE USE THIS SERVICE FOR EMERGENCIES
ONLY.
VI.
FIRE OR EARTHQUAKE PROCEDURES
A. Fire
1. The purpose of the fire procedures is to minimize hazards to
personnel and to property. If the fire alarm sounds in one of
the clinic buildings, the alarm will activate a voice broadcast
directing individuals to evacuate the building immediately. A
clinic floor warden will coordinate the evacuation process.
Revised: Apr-11
SECTION 8 – EMERGENCY PROCEDURES
The fire department and police will respond to the alarm as
quickly as possible. Paging system announcements may be
made by clinic personnel as appropriate.
2. Under the direction of the clinic floor warden, students and
faculty will be expected to assist patients in locating the fire
exits in each specific clinic and shall guide the patients to a
safe exit from the building. Clinic floor diagrams will be
posted near exits that clearly indicate the proper evacuation
routes. Do NOT use the elevators.
B. Earthquakes
1. During an earthquake, unless you are in immediate danger
as a result of an earthquake, stay indoors. Take cover under
a desk, table, or bench, in doorways, halls or against inside
walls. Stay away from windows, mirrors, skylights, glass and
furniture or objects that may fall over. Do not run for the
exits, do not use elevators and stay inside to avoid being hit
by falling debris and electrical wires. STUDENTS AND
FACULTY ARE EXPECTED TO ASSIST PATIENTS in
avoiding panic and managing their safety.
2. Do not smoke, use matches or other open flame devices.
Immediately shut off all bunsen burners or open flames. If
you smell gas, open all exterior windows and leave the
area. Check all utilities. If pipes or gas lines are leaking or
wires are shorting, turn off the utility. On-campus, report
such situations to the Physical Plant Department at
extension 6-2021 giving the exact location and nature of the
damage. Do not re-enter the area until the repair is made
and you are advised that re-entry is safe.
Revised: Apr-11
SECTION 8 – EMERGENCY PROCEDURES
C. The School of Dentistry's disaster information number is (415)
476-1891. This is the number you should call for information
regarding the status of the School. When you call the number you
will hear an announcement advising you of the operational status
of the School. It is advised that you keep a copy of this document
and phone number at your home to call if a disaster occurs during
off hours. You may phone this number to hear any updates
regarding the status of the campus and the School of Dentistry.
VII.
UCSF DENTAL CENTER BUILDING EMERGENCY NUMBERS
A. *Dial 52 and wait for dial tone to make sure line is not on forward.
Then dial the correct number.
B. Fire, Police, Medical, Hazardous Materials, Bomb Threat
(from non-campus or pay phone)
9-911
911
C. Campus Police (non-emergency)
476-1414
D. Code Blue – Parnassus
476-1234
E. Suspicious activity, theft
(emergency)
9-911
(non-emergency)
476-1414
F. Unruly or dangerous patient
9-911
G. Hazardous Material Spills
9-911
H. Needlestick or puncture wound (24 hour pager)
353-STIC(7842)
I. Poison Control
1-800-876-4766
J. Campus Emergency Information Hotline
1. (if campus phones do not work)
K. Hospital Hot-line
502-4000
1-800-873-8232
885-STAT (7828)
L. Back-Up Hospital Hotline (activated only if telephone service fails)
1-800-873-8232
M. Building damage, utilities
N. Facilities Management Information Line
476-2021 or 476-1414
514-1212
Revised: Apr-11
SECTION 8 – EMERGENCY PROCEDURES
O. UCSF Emergency Radio Broadcast Announcements
KCBS-740 AM, KGO-810 AM
VIII.
UCSF Websites – For Emergency Information
A. WarnMe (Register for Emergency Warnings)
http://www.warnme.ucsf.edu
B. UCSF Homepage
http://www.ucsf.edu
C. Police/Emergency Management
http://www.police.ucsf.edu
D. Material Safety Data Sheets-chemical info
http://www.or.ucsf.edu/ehs
E. Environmental Health and Safety
http://www.or.ucsf.edu/ehs
Revised: Apr-11
SECTION 9 – HEALTH AND SAFETY POLICIES
I.
BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN
A. Facility Name
1. University of California, San Francisco - School of Dentistry (at all its sites)
B. In accordance with the Cal/OSHA Bloodborne Pathogens Standard, the following
exposure control plan has been developed:
1. Purpose of this Plan
a. The purpose of this exposure control plan is to:
i.
Eliminate or minimize employee occupational exposure to blood or
certain other body fluids
ii.
Eliminate or minimize employee occupational exposure to blood or
certain other body fluids
2. Occupational Exposure Determination- The following is a list of job
classifications at the UCSF School of Dentistry in which employees have an
occupational exposure to bloodborne pathogens and the tasks that involve
potential exposures:
a. Job Classification: Dentists, Physicians, Scientists, Students, and
Residents with clinical responsibilities or other occupational exposure to
bloodborne pathogens (Includes: Ladder Rank Professors, Clinical
Professors, Adjunct Professors, Professors of Clinical _______, Visiting
Professors, Professors in Residence, Clinical Instructors, Clinic Directors,
Dental Specialists, and Professional Research)
b. Tasks/Procedures
i.
All phases of dental diagnosis and treatment that require use of
sharp instruments and exposure to blood and other potentially
infectious materials (OPIM)
ii.
Handling contaminated sharp instruments
iii.
Handling/working with intraoral impressions
iv.
Handling/working with removable dental prostheses
v.
Handling extracted teeth and other specimens
SECTION 9 – HEALTH AND SAFETY POLICIES
vi.
Supervising students in dental diagnosis and treatment
c. Job Classification: Registered Dental Hygienists (Includes: Professors,
Associate & Assistant Professors, Clinical Professors, Associate &
Assistant Clinical Professors, Clinical Instructors, and Hygienists)
d. Tasks/Procedures
i.
Dental hygiene treatment that requires use of sharp instruments
and exposure to blood and OPIM
ii.
Handling contaminated sharp instruments
iii.
Supervising students in dental hygiene treatment
iv.
Exposing radiographs and processing film
v.
Cleaning/disinfecting contaminated instruments and operatory
vi.
Processing instruments for sterilization
e. Job Classification: Dental Assistants (Includes: Dental Assistants, and
Registered & Supervisory Dental Assistants)
f. Tasks/Procedures
i.
Chairside assisting during all phases of dental diagnosis and
treatment that requires handling of sharp instruments and
exposure to blood and OPIM
ii.
Handling contaminated sharp instruments
iii.
Handling/working with intraoral impressions
iv.
Handling removable dental prostheses
v.
Handling extracted teeth and other specimens
vi.
Exposing radiographs and processing film
vii.
Cleaning/disinfecting contaminated instruments and operatory
viii.
Processing instruments for sterilization
g. Job Classification: Registered Dental Assistants (TC/EF)
h. Tasks/Procedures
i.
Chairside assisting during all phases of dental diagnosis and
treatment that requires handling of sharp instruments and
exposure to blood and OPIM
SECTION 9 – HEALTH AND SAFETY POLICIES
ii.
Performance of expanded functions that require use of sharp
instruments and exposure to blood and OPIM including: cord
retraction procedures, taking impressions, trail fitting of endodontic
filling points and applying pit and fissure sealants
iii.
Handling contaminated sharp instruments
iv.
Handling/working with intraoral impressions
v.
Handling removable dental prostheses
vi.
Handling extracted teeth and other specimens
vii.
Exposing radiographs and processing film
viii.
Cleaning/disinfecting contaminated instruments and operatory
ix.
i.
Processing instruments for sterilization
Job Classification: Dispensary/Central Sterilization Personnel [Includes:
Clinic Dispensary Assistants I, Hospital Assistants I, Dental Assistants,
Registered Dental Assistants, Laboratory Assistants, Stores Facility
Assistant III-Supervisors (when filling in), and Research Assistants]
j.
Tasks/Procedures
i.
Handling contaminated sharp instruments
ii.
Handling soiled laundry
iii.
Cleaning/disinfecting contaminated instruments and operatory
iv.
Processing instruments for sterilization
k. Job Classification: Radiography Technicians [Includes: Hospital
Assistants III and Administrative Assistant III-Supervisors (with patient
contact)]
l.
Tasks/Procedures
i.
Exposing radiograph
ii.
Processing film
iii.
Cleaning/disinfecting contaminated x-ray room and equipment
m. Job Classification: Laboratory Technicians (Includes: Hospital
Laboratory Technicians I and Laboratory Assistants I-IV)
n. Tasks/Procedures
SECTION 9 – HEALTH AND SAFETY POLICIES
i.
Handling impressions and casts
ii.
Handling/working with dental prostheses taken directly from
patients
iii.
Cleaning/disinfecting contaminated laboratory areas and
equipment
o. Job Classification: Research Laboratory Personnel (Includes: Research
______, Associate & Assistant Research ________, Postgraduate
Research_______, Staff Research Assistants, Research Associates,
Laboratory Assistants, and some Laboratory Helpers)
p. Tasks/Procedures
i.
Culturing cells
ii.
Performing viral and bacterial isolation and culture
iii.
Processing human tissue and body fluids
iv.
Performing centrifugation and other techniques that generate
aerosols
v.
Cleaning x-ray processors
vi.
Cleaning biohazard hoods and contaminated surfaces
vii.
Animal-related research
viii.
Transporting biohazardous material
q. Job Classification: Pathology Laboratory Personnel (Includes: Staff
Research Associates, Research Assistants, and Laboratory Assistants)
r. Tasks/Procedures
i.
Processing tissue samples, fixed and unfixed
ii.
Sectioning frozen tissue with sharp cutting instruments
iii.
Handling other sharp devices: razors, scalpels, microtomes, glass
slides and coverslips
3. The following is a list of job classifications in which employees have some
exposure to bloodborne pathogens and the tasks that involve potential
exposures:
SECTION 9 – HEALTH AND SAFETY POLICIES
a. Job Classification: Mechanicians (Includes: Principal Laboratory
Mechanician Supervisors and Senior Laboratory Mechanicians)
b. Task/Procedures
i.
Inspecting, maintain and repairing dental equipment used in
patient care
ii.
Preparing dental equipment to be sent out to other vendors for
repair
c. Job Classification: Staff who handle patient charts
d. Tasks/Procedures
i.
Handling patient charts that may have been exposed to blood or
other potentially infectious material
e. Job Classification: Laboratory Helpers (Includes: Laboratory Assistants
I-IV)
f. Tasks/Procedures
i.
Lab clean-up and disinfection
ii.
Washing contaminated glassware
iii.
Autoclaving waste
C. Implementation Methodology to Prevent Exposure to Bloodborne Pathogens
1. Universal Precautions
a. Universal precautions will be observed at this facility to prevent contact
with blood or Other Potentially Infectious Materials (OPIM). All human
blood and certain human body fluids (saliva in dentistry) are treated as if
known to be infectious for HIV, HBV, and other bloodborne pathogens.
Universal precautions mean that the same infection control procedures
are used for all patients and with all specimens.
2. Engineering Controls
a. The following engineering controls will be used to eliminate or minimize
employee exposure to bloodborne pathogens at the UCSF School of
Dentistry:
SECTION 9 – HEALTH AND SAFETY POLICIES
i.
Autoclaves will be used to decontaminate waste in research
laboratory settings and reusable sharp instruments in clinical
settings
ii.
Biosafety cabinets - laminar flow hoods - Class II will be used to
reduce bloodborne pathogen exposure in research laboratories
and some pathology laboratories
iii.
Centrifuge containers/shields will be used when the rotor is
spinning to prevent aerosol generation and reduce bloodborne
pathogen exposure in research laboratories
iv.
Dental dams will be used in patient procedures when necessary to
reduce aerosolization and droplet projectiles to dental operators
v.
Handwashing facilities will be available to all employees who incur
exposure to blood or other potentially infectious materials.
Handwashing facilities are available in each laboratory,
dispensary, and clinic, usually at each operatory
vi.
High-volume evacuation, dental dam utilization, and proper patient
positioning will be used to reduce exposure to droplets and blood.
Dental equipment (high-volume evacuators) and dental chairs are
inspected monthly and repaired as needed by school
mechanicians
vii.
Instrument cassettes, which completely enclose instruments, will
be used to reduce employee handling of sharp instruments.
Students must secure contaminated instruments into cassettes
prior to turning them into dispensary personnel for sterilization.
Students and dispensary personnel are required to identify and
eliminate any cassettes in disrepair
viii.
Sharps containers will be used for disposal of sharp instruments
and syringe needles and most often are mounted at each
operatory. Clinic managers or directors are responsible for seeing
that sharps containers are disposed of properly when full (call
SECTION 9 – HEALTH AND SAFETY POLICIES
Campus EH&S at 6-1300 for proper disposal). Clinic managers or
directors are responsible for obtaining additional sharps containers
when needed
ix.
Ultrasonic cleaners will be used to eliminate or reduce employee
handling of contaminated sharp instruments. Dispensary
personnel and clinic managers are responsible for regular
disinfection and for monitoring effectiveness of ultrasonic cleaners.
Ultrasonic cleaners will be repaired on an as-needed basis
3. Engineering Controls
a. following engineering controls will be used to eliminate or minimize
employee exposure to bloodborne pathogens at the UCSF School of
Dentistry:
i.
Autoclaves will be used to decontaminate waste in research
laboratory settings and reusable sharp instruments in clinical
settings
ii.
Biosafety cabinets - laminar flow hoods - Class II will be used to
reduce bloodborne pathogen exposure in research laboratories
and some pathology laboratories
iii.
Centrifuge containers/shields will be used when the rotor is
spinning to prevent aerosol generation and reduce bloodborne
pathogen exposure in research laboratories
iv.
Dental dams will be used in patient procedures when necessary to
reduce aerosolization and droplet projectiles to dental operators
v.
Handwashing facilities will be available to all employees who incur
exposure to blood or other potentially infectious materials.
Handwashing facilities are available in each laboratory,
dispensary, and clinic, usually at each operatory
vi.
High-volume evacuation, dental dam utilization, and proper patient
positioning will be used to reduce exposure to droplets and blood.
Dental equipment (high-volume evacuators) and dental chairs are
SECTION 9 – HEALTH AND SAFETY POLICIES
inspected monthly and repaired as needed by school
mechanicians
vii.
Instrument cassettes, which completely enclose instruments, will
be used to reduce employee handling of sharp instruments.
Students must secure contaminated instruments into cassettes
prior to turning them into dispensary personnel for sterilization.
Students and dispensary personnel are required to identify and
eliminate any cassettes in disrepair
viii.
Sharps containers will be used for disposal of sharp instruments
and syringe needles and most often are mounted at each
operatory. Clinic managers or directors are responsible for seeing
that sharps containers are disposed of properly when full (call
Campus EH&S at 6-1300 for proper disposal). Clinic managers or
directors are responsible for obtaining additional sharps containers
when needed
ix.
Ultrasonic cleaners will be used to eliminate or reduce employee
handling of contaminated sharp instruments. Dispensary
personnel and clinic managers are responsible for regular
disinfection and for monitoring effectiveness of ultrasonic cleaners.
Ultrasonic cleaners will be repaired on an as-needed basis
4. Work Practice Controls
a. In addition to the above engineering controls, the following work practice
controls will also be used:
i.
Barriers. Place plastic disposable barriers on light handles and
chair control handles. Place plastic barriers over chair and x-ray
tube in x-ray rooms. Use PPE when disposing of contaminated
barriers
ii.
Clinical Lab Safety. Wear proper PPE when performing laboratory
procedures. Exert caution when using lathes while wearing
gloves. Secure hair and loose clothing to minimize the potential for
SECTION 9 – HEALTH AND SAFETY POLICIES
cross-contamination and injury. Always use fresh pumice, a clean
disposable tray, and sterile rag wheel when using the polishing
lathe
iii.
Contaminated Needles and Sharps shall not be sheared or
purposely broken. Needles must be recapped after each use.
Recapping of needles is allowed for procedures requiring more
than one administration of anesthesia. In such cases, a onehanded recapping method is required
iv.
Debris Bag should be available for each procedure. The debris
bag does not need to be red or have the biohazard symbol unless
the procedure is reasonably expected to generate a significant
amount of blood (e.g., gauze saturated with blood to the extent that
blood drips off when squeezed). The debris bag must be
impervious to fluid
v.
Disinfect Impressions and Appliances. Always disinfect
impressions and appliances before transporting and working with
them in the clinical laboratory
vi.
Disinfection. Spray or wipe on intermediate-level hospital
disinfectant on chair, dental unit, (or cover with barrier)chair control
handles, operator and assistant chairs, handpiece handles, etc..
Wipe down high-speed tubing with a gauze saturated with
disinfectant. Allow solution to sit on surfaces for full amount of
time recommended by manufacturer (usually ten minutes). Nonsterilizable equipment used in procedures (e.g., curing lights,
amalgamators, torches) must also be disinfected between
patients).
vii.
Extracted Teeth - Return of extracted teeth is forbidden with the
exception of Pediatric Dentistry, where only teeth which do not
contain amalgam may be returned to the patient. All extracted
teeth without amalgam are to be placed into an appropriately
SECTION 9 – HEALTH AND SAFETY POLICIES
labeled container specifically for extracted teeth which do not
contain amalgam. All extracted teeth containing amalgam shall be
disposed of in an appropriately labeded container for teeth with
amalgam waste. Extracted teeth which are collected for dental
school academic purposes are to be collected as per previous
protocol
viii.
Flush Lines Adequately. Run water through air/water syringe lines,
ultrasonic lines and handpiece lines for a full two minutes prior to
the first patient of the day and for a full thirty seconds before
seating subsequent patients. Wear PPE during flushing
procedure. (American Dental Association
www.ada.org/prac/position/waterfacs.html)
ix.
Food, Drink and Cosmetics. In work areas where there is a
reasonable likelihood of exposure to blood or other potentially
infectious materials, employees are not to eat, drink, apply
cosmetics or lip balm, or handle contact lenses. Food and
beverages are not to be kept in refrigerators, freezers, shelves,
cabinets, or on counter or bench tops where blood or other
potentially infectious materials are present
x.
Hair Safety. Hair should be secured off of face in such a way that
it does not interfere with or become contaminated during
procedures
xi.
Hand Injury Prevention. Precautions should be taken to avoid
hand injuries during all procedures
xii.
Handwashing must occur before putting on gloves. Employees
must also wash hands and any other potentially contaminated skin
area with soap and water or alcohol hand sanitizer immediately
after removing gloves or as soon as feasible. (OSHA Federal
Register, page 64176, December 6, 1991). Clinic managers and
directors and laboratory managers shall ensure that, after the
SECTION 9 – HEALTH AND SAFETY POLICIES
removal of personal protective gloves, employees wash hands and
any other potentially contaminated skin area with soap and water
immediately or as soon as feasible
xiii.
Instrument Handling. During procedures, all devices and
instruments should be placed in such a way to reduce accidental
injuries. For example, handpieces should be placed into hangers
with burs pointing in a direction that would reduce accidental
injuries. Burs should be removed from handpieces after every
procedure. While burs are attached to the handpiece and in the
holder, place a plastic dixie cup over handpiece to prevent
accidental injury
xiv.
Mouth-Pipetting/Suctioning of blood or other potentially infectious
materials in research laboratories is absolutely prohibited
xv.
Overgloves should be worn over exam gloves whenever leaving
the operatory or during a procedure to prevent contamination of
surfaces or of clean items
xvi.
Processing Contaminated Equipment. Equipment repair personnel
are responsible for ensuring that equipment that has become
contaminated with blood or other potentially infectious materials is
examined prior to servicing or shipping and is decontaminated as
necessary. If decontamination of the equipment is not feasible, it
will be labeled with a biohazard label
xvii.
Processing Reusable Sharp Instruments. All sharp instruments
must be secured in locked cassette before being placed in
puncture-resistant, labeled, leak-proof container for proper
processing. Employees and students must not reach into such
containers. When handling becomes necessary, instruments
should be poured from the container onto a flat surface without
being touched. Then instruments may be handled using heavy
SECTION 9 – HEALTH AND SAFETY POLICIES
utility gloves and appropriate instrument pick-up forceps.
Instruments should be grasped carefully to avoid sharp surfaces.
xviii.
Recap Needles using a one-handed method. Never use two
hands to recap needles, and always recap syringe needles
between use. If safety needles are used, the manufacturer’s
directions for handling the needles must be followed
xix.
Specimens of Blood or Other Potentially Infectious Materials will be
placed in a container that prevents leakage during the collection,
handling, processing, storage, transport, and shipping of the
specimens. The container used for this purpose will be properly
labeled or color coded and closed prior to storage, transport, and
shipping. Also, all specimens must be placed within a secondary
container that is puncture resistant. If outside contamination of the
primary container occurs, the primary container shall be placed
within a secondary container. Secondary containers shall meet all
the requirements for primary containers
xx.
Splash/Spray Prevention. All procedures will be conducted in a
manner that minimizes splashing, spraying, splattering, and
generation of droplets of blood or other potentially infectious
materials
xxi.
Sterilization. All instruments must be sterilized between patients,
including high speed handpieces, slow speed motors and all
attachments. Autoclaves and other sterilizers must be monitored
with a biological monitoring device daily. Cold-solution sterilization
methods areno longer used. If a cold-solution method is used, the
clinic must develop a system for monitoring how often the solution
is changed and how long instruments are submerged in the
solution. Manufacturer recommendations must be precisely
followed
D. Personal Protective Equipment (PPE) General Requirements
SECTION 9 – HEALTH AND SAFETY POLICIES
1. PPE Provision. Each clinic director or manager or laboratory manager is
responsible for ensuring that the following provisions are met. All personal
protective equipment used at this facility will be provided without cost to
employees. The protective equipment will be considered appropriate only if it
does not permit blood or other potentially infectious materials to pass through or
reach the employee's clothing, skin, eyes, mouth, or other mucous membranes
under the normal conditions of use and for the duration of time that the
protective equipment will be used. Personal protective equipment is available at
or near the dispensary area in each clinic or at a central location in each
research laboratory. All personal protective equipment will be the correct size,
be clean and in good repair, and fit properly.
2. PPE Use & Accessibility. Each clinic director or manager or laboratory manager
shall ensure that the employee uses appropriate PPE. Each clinic director or
manager or laboratory manager shall ensure that appropriate PPE in the
appropriate sizes is readily accessible at the work site and is issued without cost
to employees. Hypoallergenic gloves, glove liners, powder free gloves, or other
similar alternatives shall be readily accessible to those employees who are
allergic to the gloves normally provided
3. PPE Cleaning, Laundering and Disposal. All personal protective equipment will
be cleaned, laundered, and/or disposed of at no cost to the employees. All
necessary repairs and replacements will also be made at no cost to employees.
All garments penetrated by blood shall be removed immediately or as soon as
feasible. All PPE will be removed prior to leaving the work area. When PPE is
removed, it shall be placed in an appropriately designated area or container for
storage, washing, decontamination, or disposal.
E. Personal Protective Equipment - Specific Policies
1. Eye and Face Protection. Masks in combination with eye protection devices,
such as goggles or glasses with solid side shields or chin length face shields,
are required to be worn whenever splashes, spray, splatter, or droplets of blood
or OPIM may be generated and eye, nose, or mouth contamination can be
SECTION 9 – HEALTH AND SAFETY POLICIES
reasonably anticipated. Although OSHA states “Masks in combination with eye
protection devices, such as goggles or glasses with solid side shield, or chin
length face shields shall be worn whenever splashes, spay, spatter, or droplets
of blood or other potentially infectious materials may be generated and eye,
nose or mouth contamination can be reasonably anticipated,” it is a school policy
to wear eye and face protection whenever an operator is accessing the mouth.
In addition to a surgical mask, a full faceshield is required whenever using an
ultrasonic scalar. Eyewear or other means of eye protection shall be used by
patients during all procedures when chair is reclined
2. Gloves shall be worn when it is reasonably anticipated that employees will have
hand contact with blood, non-intact skin, mucous membranes, or other
potentially infectious materials (OPIM) during a dental procedure and when
handling or touching specimens, contaminated items, or surfaces. Single-use
disposable gloves used at this facility are to be disposed of after one use (i.e.,
are not to be washed or decontaminated for re-use), or if they are torn,
punctured, or when their ability to function as a barrier is compromised. Utility
gloves may be decontaminated for re-use provided that the integrity of the
gloves is not compromised. Utility gloves will be discarded if they are cracked,
peeling, torn, punctured, or exhibit other signs of deterioration or when their
ability to function as a barrier is compromised. Latex surgical gloves are
provided for procedures that generate a significant amount of blood (e.g., oral
surgery and periodontal surgery). Over-gloves are to be used whenever a
chance of cross contamination of surgical gloves occurs. Overgloves must be
worn over surgical gloves when leaving the cubicle and when obtaining items
from the dispensary
3. Gowns must be worn in patient treatment areas during all dental procedures,
including set-up, and clean-up and must be changed after each clinic session
when visibly soiled or soaked through with blood or OPIM. Gowns must be
disposed of in the proper location, and they must not be worn outside of the
clinic areas, except for transfer between clinic areas in the Dental Clinics
SECTION 9 – HEALTH AND SAFETY POLICIES
Building. White laboratory coats may be worn only for consultation procedures
that do not require the use of gloves or instruments. Closed- toed shoes must be
worn in the clinics. Hair must be pulled back away from the face so that it does
not come in contact with the patient
4. Additional Protective Clothing shall be worn in instances when gross
contamination can be reasonably anticipated. Some oral surgery or periodontal
procedures may require additional protective clothing and impervious aprons or
gowns. Hair and shoe covers are available for any dental procedures that
generate significant spatter or aerosols
5. NOTE: An Infection Control Checklist (see Appendix A), with excerpts from the
above three sections on engineering controls, work practice controls, and
personal protective equipment, will be displayed in each clinic, preferably at
each operatory
6. Professional Attire: All faculty, staff, and students must comply with the
following guidelines for professional attire, which are in effect in all clinics of the
University of California San Francisco, School of Dentistry
7. Personal Hygiene
a. Hair
i.
Hair should be clean and well groomed. When working with
patients, hair must be kept secured away from the face and front of
gown and out of the field of operation so that it does not require
handling during any treatment procedure
ii.
Men must be clean-shaven or beards and mustaches must be
clean, neatly trimmed, and well groomed
b. Personal Cleanliness
i.
Body hygiene is required so that offensive body odor is avoided
ii.
Strong perfumes, colognes, or after-shave lotions should be
avoided
c. Fingernails
i.
Hands and fingernails must be kept immaculately clean
SECTION 9 – HEALTH AND SAFETY POLICIES
ii.
Fingernails must be kept trimmed and well manicured
iii.
Artificial fingernails are strictly forbidden
d. Jewelry
i.
All jewelry should be kept out of the field of operation (Example:
dangling earrings, necklaces).
ii.
Jewelry should be limited to minimal hand and wrist jewelry (rings,
watches, bracelets).
8. General Clinic Attire
a. Men: Collared shirt (optional necktie), trousers, socks, and closed dress
shoes
b. Women: Skirt or slacks with blouse or a dress. Slacks must reach the
ankle. Skirts, dresses, or culottes must be at approximate knee length or
longer. Hosiery must be worn with skirts and dresses, and socks or
hosiery must be worn with slacks. Closed dress shoes/dress boots must
be worn.
c. Scrubs
i.
Clean, matching upper and lower scrubs may be worn as an
alternative to the clothing listed above
ii.
T-shirts or short-sleeved shirts may be worn under scrubs
iii.
Any clean, closed-toe, solid color shoes may be worn
iv.
Socks are required
v.
Color of scrubs must conform to appropriate clinic gown color
(currently light blue for dental and dental hygiene students and
green for faculty).
vi.
A variety of colors or patterns of scrubs may be used by staff
d. Gowns
i.
Clinic gowns must be worn by students at all times when providing
patient care or while handling contaminated instruments and
equipment during clean-up
ii.
Clinic gowns must be worn on top of the clothing listed above
SECTION 9 – HEALTH AND SAFETY POLICIES
iii.
Only gowns provided by the dental school may be used
iv.
Gowns must be changed daily or more often if visibly soiled with
blood
v.
Name tags with students name and number must be worn on gown
when in clinic
e. The following items are not permitted
i.
Jeans, stirrup pants, tights alone, leggings, mini-skirts, sweats, and
shorts
ii.
Tee shirts (unless underneath scrubs) and sweatshirts
iii.
Denim or denim-like fabrics
iv.
Hats or caps
v.
Open-toe shoes, sling backs, moccasins or sandals
f. Identification must be worn at all times in the clinical setting (name labels
on gowns or UCSF ID at other times).
g. Behavioral considerations
i.
Eating, drinking, applying cosmetics and handling contact lenses in
any work area where there is a reasonable likelihood of
occupational exposure is prohibited. This includes all clinic and
laboratory areas
9. Housekeeping- The UCSF School of Dentistry clinics and research facilities
must be maintained in a clean and sanitary condition. Employees must
decontaminate any areas, surfaces, or equipment that become contaminated
with blood or OPIM, according the following schedule:
a. Decontamination
i.
Patient care areas (operatories, lab areas, x-ray room) will be
decontaminated with an appropriate EPA-approved disinfectant
immediately after a procedure and the patient has been dismissed
or after any spill of blood or OPIM
SECTION 9 – HEALTH AND SAFETY POLICIES
ii.
Research lab areas will be decontaminated with an appropriate
EPA-approved disinfectant immediately following a procedure that
involves blood, unfixed tissue, or OPIM
b. Protective Barriers
i.
Wherever possible, disposable protective barriers will be used on
surfaces that are likely to become contaminated during a
procedure (e.g., coverings over light handle covers; plastic tubing
over air/water syringe handles). Such protective coverings must
be replaced between patients or if they have become overtly
contaminated during a procedure
c. Reusable Bins, Pails, or Other Receptacles
i.
Reusable containers must be inspected daily and decontaminated
with an appropriate disinfectant if they are visibly contaminated
with blood or OPIM
d. Broken Glassware
i.
Contaminated broken glassware should not be picked up by hand,
but rather picked up with tongs, forceps, or a brush and dustpan
and placed in sharps container
e. Handling Spills of Blood or OPIM
i.
Major spills of blood or OPIM should first be decontaminated with
an EPA-approved disinfectant. The spill should then be wiped up
and disposed of as regular trash. Proper personal protective
equipment (gloves, mask, gown) must be worn while cleaning
spills
F. Regulated Waste Disposal
1. Disposable Sharps
a. Contaminated sharps shall be discarded immediately or as soon as
feasible in containers that are closable, puncture resistant, leak proof on
sides and bottom, and properly labeled
SECTION 9 – HEALTH AND SAFETY POLICIES
b. In the UCSF Dental Clinics, sharps containers are mounted on the wall of
each operatory. An adequate number of properly secured sharps
containers are also available in research and pathology laboratories
c. The containers shall be maintained upright throughout use, replaced
routinely, and not be allowed to overfill. Observe the “full line” on the
sharps container
d. When moving containers of contaminated sharps from the area of use,
the containers shall be closed immediately prior to removal or
replacement to prevent spillage or protrusion of contents during handling,
storage, transport, or shipping
e. The container shall be placed in a secondary container if leakage of the
primary container is possible. The second container shall be closeable,
constructed to contain all contents and prevent leakage during handling,
storage and transport, or shipping. The second container shall be
properly labeled to identify its contents. Call Campus Environmental
Health & Safety at x6-1300. They will pick up sharps containers for
proper disposal
f. Reusable containers shall not be opened, emptied, or cleaned manually
or in any other manner that would expose employees to the risk of
percutaneous injury
2. Non-Sharps Regulated Waste
a. Other regulated waste (e.g., saturated bloody gauze, etc.) shall be
placed in containers that are closeable, are constructed to contain all
contents, and prevent leakage of fluids during handling, storage,
transport, or shipping
b. The waste bag or container must be labeled, color coded, and closed
prior to removal to prevent spillage or protrusion of contents during
handling, storage, transport, or shipping. Do not place red bags into
regular trash. Call Campus Environmental Health & Safety at x6-1300 for
SECTION 9 – HEALTH AND SAFETY POLICIES
disposal. Non-sharps regulated waste in research labs should be
autoclaved prior to disposal
3. Evacuation Line Waste
a. Liquid waste containing blood or OPIM which is collected through the
high-speed evacuation system may be disposed of through the regular
sewage system
4. Other Waste
a. Waste that is not regulated or medical waste, but is contaminated with
small quantities of blood or OPIM (e.g., 2x2 gauze with small amount of
blood or saliva), must be placed into an impervious paper or plastic bag,
sealed, and disposed of in regular trash. As this is not regulated or
medical waste, the bags should not be red, orange, or contain the
biohazard label. However, this waste should be handled with proper PPE
G. Laundry Procedures
1. Laundry contaminated with blood or other potentially infectious materials will be
handled as little as possible and with minimum agitation. Such laundry will be
placed and transported in a leak-proof cart for soiled laundry. At the UCSF
Dental Clinics, all soiled laundry is picked up and laundered by the UCSF
laundry facility. This facility uses universal precautions in processing all laundry.
Dental clinic employees should wear personal protective equipment if they ever
need to handle soiled laundry. Employees must not take PPE home to launder
H. Hepatitis B Vaccine
1. General - The UCSF School of Dentistry shall make the Hepatitis B vaccine and
vaccination series available to all employees who are at risk for occupational
exposure and post-exposure follow-up to employees who have had an exposure
incident. The vaccine shall be:
a. Made available at no cost to the employees
b. Made available to the employee at a reasonable time and place
c. Performed by or under the supervision of a licensed physician or other
health care professional
SECTION 9 – HEALTH AND SAFETY POLICIES
d. Provided according to the recommendations of the U.S. Public Health
Service
2. All laboratory tests shall be conducted by an accredited laboratory at no cost to
the employee.
I. Hepatitis B Vaccination Implementation
1. The School of Dentistry Health & Safety Director and the department
management services officers are responsible for implementing the Hepatitis B
vaccination program. We contract with the UCSF Occupational Health Service
to provide the service
2. Hepatitis B vaccination shall be made available after the employee has received
the training in occupational exposure (see information and training) or within ten
working days of initial assignment to all employees who have occupational
exposure, unless the employee has previously received the complete Hepatitis B
vaccination series, antibody testing has revealed that the employee is immune,
the vaccine is contraindicated for medical reasons, or the employee signs a
statement of declination
3. Participation in a pre-screening program shall not be a prerequisite for receiving
Hepatitis B vaccination
4. If the employee initially declines Hepatitis B vaccination, but later decides to
accept the vaccination while still covered under the standard, the vaccination
shall then be made available
5. All employees who have any exposure to blood or OPIM will complete and sign
a Hepatitis B Vaccine Information/Consent/Declination form (Appendix B).
6. If a routine booster dose of Hepatitis B vaccine is recommended by the U.S.
Public Health Service at a future date, such a dose shall be made available
J. Post Exposure Evaluation and Follow-Up
1. All exposure incidents shall be reported, investigated, and documented. When
the employee incurs an exposure incident, it shall be reported to the appropriate
clinic director, department manager, or laboratory manager. The responsible
party should fill out a Workers Compensation Report form, Environmental Health
SECTION 9 – HEALTH AND SAFETY POLICIES
& Safety Accident form, and an Injury or Illness Investigation form. After any
exposure, including a needle stick, the employee should be referred to the 24hour UCSF Needle stick Hotline at 353-STIC (7842) for further information and
immediate treatment and counseling by the UCSF Employee Health Service
2. Following a report of an exposure incident, the exposed employee shall
immediately receive a confidential medical evaluation and follow-up, including at
least the following elements:
a. Documentation of the route of exposure and the circumstances under
which the exposure incident occurred
b. Identification and documentation of the source individual, unless it can be
established that the identification is not feasible or is prohibited by state or
local law
c. The source individual's blood shall be tested as soon as is feasible and
after consent is obtained to determine bloodborne pathogens infectivity
d. When the source individual is already known to be infected with HBV or
HIV, testing for the source individual's known HBV or HIV status need not
be repeated
e. Results of the source individual's testing shall be made available to the
exposed employee, and the employee shall be informed of applicable
laws and regulations concerning disclosure of the identity and infectious
status of the source individual
3. Collection and testing of blood for HBV and HIV serological status will comply
with the following:
a. The exposed employee's blood shall be collected as soon as is feasible
and tested after consent is obtained
b. The employee will be offered the option of having his/her blood collected
for testing for HIV/HBV serological status. The blood sample will be
preserved for up to ninety days to allow the employee to decide if the
blood should be tested for HIV serological status
SECTION 9 – HEALTH AND SAFETY POLICIES
4. All employees who incur an exposure will be offered post-exposure evaluation
and follow-up in accordance with the Cal/OSHA standard. The UCSF
Occupational Health Service is highly experienced at providing post-exposure
follow-up, though an employee may go elsewhere for care
K. Information Provided to the Healthcare Professional
1. The employee's supervisor shall ensure that the health care professional
responsible for the Hepatitis B vaccination and for evaluating the employee after
an exposure incident is provided the following additional information:
a. A copy of the Bloodborne Pathogens regulation (while the standard
outlines the confidentiality requirements of the health care professional, it
might be helpful for the employer to remind that individual of these
requirements)
b. A written description of the exposed employee's duties as they relate to
the exposure incident
c. Written documentation of the route of exposure and circumstances under
which exposure occurred
d. Results of the source individual's blood testing, if available
e. All medical records relevant to the appropriate treatment of the employee,
including vaccination status
L. Healthcare Professional's Written Opinion
1. The employee's supervisor shall obtain and provide the employee with a copy of
the evaluating health care professional's written opinion within fifteen days of the
completion of the evaluation. The health care professional's written opinion for
HBV vaccination and post-exposure follow-up shall be limited to the following
information:
a. Whether vaccination is indicated for employee and if employee has
received such vaccination
b. A statement that the employee has been informed of the results of the
evaluation
SECTION 9 – HEALTH AND SAFETY POLICIES
c. A statement that the employee has been told about any medical
conditions resulting from exposure to blood or other potentially infectious
materials, which require further evaluation or treatment
2. Note: All other findings or diagnoses shall remain confidential and shall not be
included in the written report
M. Labels and Signs
1. The School Health & Safety Director or department management services
officers shall ensure that biohazard labels are affixed to containers for regulated
waste, refrigerators and freezers containing blood or other potentially infectious
materials, and other containers used to store, transport, or ship blood or other
potentially infectious materials. Employees will handle labeled substances or
equipment with appropriate PPE.
2. The label shall include the universal biohazard symbol and the legend
BIOHAZARD. In the care of regulated waste, the word BIOHAZARDOUS
WASTE may be substituted for the BIOHAZARD legend. The label shall be
fluorescent orange or orange-red.
3. Red regulated waste bags or containers must also be labeled.
4. Biohazard signs are posted in research labs in which HIV and HBV are present.
These signs include the following information:
a. Biohazard symbol in fluorescent orange-red
b. Name of infectious agent
c. Special requirements for entering area
d. Name and telephone number of responsible person
N. Information and Training
1. The School Health & Safety Director or department management services
officers shall ensure that training is provided to the employees at the time of
initial assignment to tasks where occupational exposure may occur, and that it
shall be repeated within twelve months of the previous training. Training shall
be provided at no cost to the employee and at a reasonable time and place.
Training shall be tailored to the education and language level of the employee
SECTION 9 – HEALTH AND SAFETY POLICIES
and offered during the normal work shift. The training will be interactive and
include the following elements:
a. An accessible copy of the standard and an explanation of its contents
b. A discussion of the epidemiology and symptoms of bloodborne diseases
c. An explanation of the modes of transmission of bloodborne pathogens
d. An explanation of the UCSF School of Dentistry Bloodborne Pathogen
Exposure Control Plan (this program), and a method for obtaining a copy
e. The recognition of tasks that may involve exposure
f. An explanation of the use and limitations of methods to reduce exposure,
for example, engineering controls, work practices, and personal protective
equipment (PPE)
g. Information on the types, use, location, removal, handling,
decontamination, and disposal of PPEs
h. An explanation of the basis for selection of PPEs
i.
Information on the Hepatitis B vaccination, including efficacy, safety,
method of administration, benefits, and that it will be offered free of
charge
j.
Information on the appropriate actions to take and persons to contact in
an emergency involving blood or OPIM
k. An explanation of the procedures to follow if an exposure incident occurs,
including the method for reporting and medical follow-up
l.
Information on the evaluation and follow-up required after an employee
exposure incident, including employee rights
m. An explanation of the signs, labels, and color-coding systems
2. The person conducting the training shall be knowledgeable in the subject matter.
Employees who have received training on bloodborne pathogens in the twelve
months preceding the effective date of this policy shall receive training only in
the provisions of the policy that were not covered
3. Additional training shall be provided to employees when there are any changes
of tasks or procedures affecting the employee's occupational exposure
SECTION 9 – HEALTH AND SAFETY POLICIES
O. Recordkeeping
1. Medical Records
a. A Hepatitis B Vaccine Information/Consent/Declination form will be
maintained in each affected employee's personnel file in his or her unit.
Once an exposure has occurred and the employee contacts UCSF
Employee Health Service, Employee Health will create and maintain the
employee's medical record
b. Medical records shall be maintained in accordance with T8 California
Code of Regulation Section 3204. These records shall be kept
confidential and not disclosed without the employee's written consent and
must be maintained for at least the duration employment plus thirty years.
The records shall include the following:
i.
The name and social security number of the employee
ii.
A copy of the employee's HBV vaccination status, including dates
of vaccination and ability to receive vaccination
iii.
A copy of all results of examination, medical testing, and follow-up
procedures
iv.
A copy of the information provided to the health care professional,
including a description of the employee's duties as they relate to
the exposure incident and documentation of the routes of exposure
and circumstances of the exposure
v.
A confidential copy of the health care professional's opinion
2. Training Records
a. The Campus Environmental Health & Safety office is responsible for
maintaining training records for three years from the date of training. The
following information shall be documented:
i.
The dates of the training sessions
ii.
An outline describing the material presented
iii.
The names and qualifications of persons conducting the training
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iv.
The names and job titles of all persons attending the training
sessions
3. Availability
a. The employee's records shall be made available to the employee or his
designated representative for examination and copying upon request in
accordance with T8CCR-GISO Section 3204. All employee records shall
be made available to the Chief of the Division of Occupational Safety and
Health (DOSH) and the National Institute of Occupational Safety and
Health (NIOSH).
4. Transfer of Records
a. If this facility is closed or there is no subsequent employer to receive and
retain the records for the prescribed period, the Chief of DOSH shall be
contacted for final disposition in accordance with Section 3204
P. Protecting Outside Contractors, Vendors, and Visitors from Exposure to Bloodborne
Pathogens
1. Temporary Clinic Employees
a. The principal employer (the temporary agency) is responsible for
providing basic bloodborne pathogens training and for offering the HBV
immunization series for its clinic employees. The temporary agency
should be able to provide documentation of the items described above
b. The temporary employer (UCSF) is responsible for orienting the
employee to the hazards of the specific job (site specific training).
Temporary employees are required to follow the same safety
requirements of all other employees as outlined in this Exposure Control
Plan. Temporary clinic employees should be offered a copy of the
Exposure Control Plan
2. Temporary Administrative Employees
a. Although temporary administrative employees are unlikely to encounter
bloodborne pathogens while carrying out their duties, supervisors should
instruct such employees about the nature of the clinic and laboratory
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spaces around which they work. Such employees should be reminded,
for example, not to enter certain areas without proper personal protective
equipment, not to eat or drink in clinic or laboratory areas, and should be
instructed to exercise caution when encountering an unidentified leak or
spill. In general, administrative employees should be made aware of the
mixed-use nature of School of Dentistry facilities and should look for
hazard posters and safety information in clinic and research laboratory
areas
b. Similar warnings and information should be provided regularly to visitors
or vendors who enter clinic or research laboratory spaces
3. Outside Construction Workers
a. Outside construction workers or contractors are generally hired through
the UCSF Facilities Management Department. Construction workers are
usually required to have some experience in a hospital or research
laboratory setting and should be familiar with the associated hazards
b. The UCSF Facilities Management Department is responsible for orienting
the construction workers to potential hazards in a construction zone.
However, the School of Dentistry department or unit is responsible for
posting hazards and proper protective equipment use in a particular area
Q. Exposure Control Plan Evaluation and Review
1. The School of Dentistry Health & Safety Policy Committee, chaired by the Dean,
is responsible for annually reviewing this program and its effectiveness and for
updating this program as needed
SECTION 9 – HEALTH AND SAFETY POLICIES
APPENDIX A
UCSF SCHOOL OF DENTISTRY
INFECTION CONTROL CHECKLIST

Cleaning of surfaces. Use appropriate disinfectant/detergent material to wipe down all items listed below
before disinfecting.

Disinfect surfaces. Spray intermediate-level, hospital disinfectant or use wet disinfectant wipes on chair, dental
unit, chair control handles, operator and assistant chairs, handpiece hangers, and so forth. Wipe down highspeed
tubing with disinfectant wipes or gauze saturated with disinfectant solution (do not spray directly). Allow
solution to sit on surfaces for a full ten minutes for complete disinfectant action.

Disinfect non-sterilizable equipment. This includes any curing lights, amalgamators, torches, etc. you plan to
use for your procedure.

Place barriers. Use appropriate barriers to cover light handles, headrest, operator chair controls, and other
surfaces as appropriate.

Place debris bag. Make sure you have a new, impermeable debris bag for each new patient procedure.

Flush lines. Run water through air/water syringe lines, handpiece lines for a full two minutes prior to
connecting the high speed handpiece and seating the first patient of the day and for a full 30 seconds prior
to seating subsequent patients. Flush a combination of air and water through the evacuation line to help clear
bioburden at the beginning and end of each procedure.

Wear personal protective equipment. Put on gown, mask and eyewear before seating patient or using
disinfectant solutions. Eyewear must include side shields on all glasses or a full face shield. Shoes must be
close-toed. Gloves should be placed on last- just before touching patient.

Hands, Gloves, Overgloves and Masks: Wash hands prior to donning clean gloves. Gloves must be worn
whenever patient is touched. Gloves must be changed whenever cross-contamination or when reasonable
suspicion of cross-contamination exists. Masks must be changed between patients or more frequently if they
become wet or contaminated with blood.

Hair and Jewelry. Tie hair back so that it is away from the face and front of gown and out of the field of
operation so that it does not require handling during any treatment procedure. Limit jewelry to rings and
simple wrist jewelry (watches and bracelets). Avoid dangling earrings.

Set out sterile items. All instruments, including handpieces, must be heat sterilized. Sterile items must be
placed in a disinfected zone and opened with gloved hands, preferably in view of the patient.
SECTION 9 – HEALTH AND SAFETY POLICIES

Wear overgloves whenever there is a chance of cross-contamination of your already gloved and contaminated
hands. Wear overgloves when leaving the operatory or when obtaining items from the dispensary.

Use a sharps container for proper disposal of syringe needles, suturing needles, anesthetic carpules, scalpel
blades, orthodontic wires and endodontic files. Dispose of other waste and transport contaminated
instruments properly.

Recap needles properly. Use one of the accepted single-handed methods for recapping needles.

Disinfect impressions and appliances. Always disinfect impressions and appliances at the operatory before
taking or sending them to the lab.

Patient Eyewear. Be sure to give each patient eyewear for all procedures in which patient is reclined. The
patient’s own prescription glasses may be worn.
No food or drink items are allowed in the clinic or lab areas.

SECTION 9 – HEALTH AND SAFETY POLICIES
APPENDIX B
HEPATITIS B VACCINE INFORMATION/CONSENT/DECLINATION
PRINT NAME:______________EMPLOYEE NUMBER________________DATE:_____________
THE DISEASE: Hepatitis B is a viral infection caused by hepatitis B virus (HBV) which causes death in 1% to 2% of patients. Most
people with hepatitis B recover completely, but approximately 5% to 10% become chronic carriers of the virus. Most of these people
have no symptoms, but an continue to transmit the disease to others. The virus is highly contagious through exposure to blood,
blood-stained secretions and by sexual route. Some may develop liver disease, such as chronic active hepatitis, cirrhosis, or liver
cancer. Thus, immunization against hepatitis B can prevent acute hepatitis and also reduce sickness and death from chronic liver
disease.
Health care workers with direct patient contact are a increased risk for acquiring hepatitis B infection. Each year in the U.S. more
than 12,000 health care workers contract hepatitis B while caring for patients, and about 300 of those infected die of liver-related
disease. A health car worker who received an accidental needlestick from an infected patient has a 40% chance of becoming
infected.
THE VACCINE: Hepatitis B vaccine is a non-infectious subunit viral vaccine manufactured in a purified form by recombinant DNA
technology using yeast cells. It is not a blood product. 90% to 100% of healthy people who receive three doses demonstrate
seroconversion and evidence of protective antibodies (anti-Hbs) and protection against hepatitis B. Full immunization requires three
doses. There is no evidence that the vaccine has ever caused hepatitis B. Persons who have been infected with HBV will not benefit
from immunization. The duration of immunity is unknown at this time, and the need for a booster dose is not yet defined. This
vaccine is contraindicated in patients who are hyper sensitive to yeast.
POSSIBLE VACCINE SIDE EFFECTS: The incidence of side effects is very low. A few persons experience tenderness and redness
at the site of injection. Low grade fever may occur. Rash, nausea, joint pain and mild fatigue have also been reported. The
possibility exists that more serious side effects may be identified with more extensive use.
If you have any questions about hepatitis B or the hepatitis B vaccine ask your doctor or Employee Health
CONSENT FORM
I have read the above statement about hepatitis B and the hepatitis B vaccine. I have had an opportunity to ask questions and
understand the benefits and risks of hepatitis B vaccination. I understand that I must have three doses of vaccine to confer immunity.
However, as with all medical treatment, there is no guarantee that I will become immune or that I will not experience an adverse side
effect from the vaccine. I request that it be given to me.
SIGNATURE:__________________________
VACCINATED/IMMUNE
( ) I have received the Hepatitis B Vaccine. What year?____________
( ) Positive blood titer. What year?____________
( ) Vaccine contraindicated for medical reasons.
SIGNATURE___________________________
DECLINATION
I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring
hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine at no charge to myself.
However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of
acquiring Hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood or other potentially
infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.
SIGNATURE_____________________________
SECTION 9 – HEALTH AND SAFETY POLICIES
II.
SECTION 9 – HEALTH AND SAFETY POLICIES
II. HAZARD COMMUNICATION PROGRAM
1. Facility Name: University of California, San Francisco School of Dentistry (at
all its sites)
2. Date of Preparation:
April, 2000
3. Purpose of this Plan
1. In order to comply with federal, state, and city regulations, the School of
Dentistry has made a commitment to provide information about safe
work procedures and chemical hazards, as well as other potential
hazards, to its faculty, staff, and students. This commitment will be met
by instituting a documented policy of employee training that fully
explains job hazards and safe work procedures prior to job assignment.
To ensure that safe work procedures are followed, unannounced
laboratory and/or clinic inspections will be conducted by members of the
various school safety committees and Environmental Health & Safety
(EH&S) staff.
2. New Employee Training
i. At his or her departmental orientation, prior to beginning work,
each new employee will be given access to the School of
Dentistry Hazard Communication Program. Personnel analysts
in the various units will be responsible for giving instructions to
employees on how to gain access to all policies.
ii. Each new employee will be asked to sign a form, prior to
beginning work, that verifies that he or she has read these
documents and understands his or her rights regarding a safe
work place (Appendix C).
iii. Because of the wide variety of activities conducted within the
unit, each clinic director or supervisor will be responsible for
instructing his or her workers regarding:
1. safe working procedures for the specific hazardous
substances to which they may be exposed
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2. the location(s) where hazardous substances are used
3. techniques used to determine the presence or release of
hazardous substances to which they may be exposed
4. explanation of the physical and health effects of the
hazardous substances to which they may be exposed
5. emergency and first-aid procedures to be followed if a
worker is exposed to a hazardous substance
6. proper procedures for the disposal of hazardous
chemicals
3. General Comments
i. To determine whether a product is hazardous, look on the label
for warnings (look for words such as "caustic", "flammable",
"toxic", etc.) or ask these questions:
1. Is it poisonous when ingested, touched, or inhaled?
2. Does it ignite?
3. Could an explosion occur if it is improperly stored, spilled,
or mixed with other products?
ii. If you have determined a product is hazardous, see your
supervisor for information on proper handling and to find out what
personal protective equipment you should wear. Never dispose
of hazardous substances in regular trash or by pouring them
down the drain. Call Campus Environmental Health & Safety at
extension 6-1300 for pick-up and disposal
4. Location and Availability of University and Departmental Hazard
Communication Program Documents and MSDS File
i. School personnel can readily obtain Material Safety Data Sheets
(MSDSs) for all dental materials listed on the school's hazardous
materials inventory and for non-dental materials via the Internet
at the following websites:
1. http://www.chem.uky.edu/resources/msds.html
SECTION 9 – HEALTH AND SAFETY POLICIES
2. http://haz1.siri.org/msds/index.html
3. http://www.nwfsc.noaa.gov/msds.html
4. http://ucsbuxa.ucsb.edu/EHandS/MSDS.html
5. http://hazard.com/msds
ii. Should you wish or need to obtain MSDS information during nonworking hours or on your own, you may access the MSDS
information via the Internet by following these directions:
1. From a designated computer in your building, connect to
your Internet system
2. These computers will be book-marked directly to the
MSDS resources. Look under ‘bookmarks’ for MSDS and
connect
3. If there is no MSDS book-marked in your system, or if you
are not using one of the designated computers listed, go
to the UCSF home page. (You will automatically be
connected to the UCSF home page when you connect to
your Internet from a UC computer). Connect to items
under the letter E
4. Connect to Environmental Health and Safety
5. Connect to MSDS
6. Suggested web sites are Vermont SIRI and Cornell
University. These are the sites which our EH&S
department frequently uses to obtain MSDS information
7. Follow the instructions at these sites, preferably by using
the chemical name in the search. If the chemical name is
not known, then the product name may be used
iii. The EH&S department does maintain a file of hard copy MSDS
sheets, however, they recommend using the Internet as the
information is more easily accessible
SECTION 9 – HEALTH AND SAFETY POLICIES
iv. The following sites have computers available for use in obtaining
MSDS information:
1. Parnassus Clinics, room D-4003
2. Oral Surgery, room S-738
3. Stomatology/Oral Medicine, S-612
4. Center for Craniofacial Anomalies, room C747
5. Buchanan Dental Center, 100 Buchanan Street
6. Periodontology Faculty Practice c/o C-628J
v. Should you wish to obtain information concerning MSDS sheets
and have difficulty using the Internet or finding the wanted
information during normal working hours, you may call EH&S at
476-1300 and ask for a representative to assist you in obtaining
MSDS information. EH&S maintains an EMERGENCY response
service 24 hours a day, which may be reached by calling 9911
from a UC phone. You may describe the nature of your call and
the emergency operator will direct your call to an on-call EH&S
representative. This would most often be used for chemical
spills, or industrial accidents. PLEASE USE THIS SERVICE
FOR EMERGENCIES ONLY
5. Hazardous Container Labeling Policy
i. It is the policy of the School of Dentistry and the responsibility of
the clinic director or supervisor to ensure that all primary
(manufacturer's) containers of hazardous substances meet the
following requirements:
1. the name and address of the manufacturer is listed
2. contents are clearly labeled
3. appropriate hazard warnings are present (flammable,
carcinogenic, etc.)
ii. Each clinic director or supervisor is also responsible for ensuring
that secondary containers of hazardous substances are properly
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labeled. Secondary containers are those into which substances
are transferred from the original manufacturer's container.
Secondary containers must be labeled with contents and hazard
warnings. Small quantities of materials that are in secondary
containers for immediate use need not be labeled
6. Training
i. Employees will receive training in hazard communication at least
once every year or as needed. Training shall explain university
and departmental hazard communication programs, review the
MSDS system, discuss safe work procedures, and review
hazardous substance container labeling procedures
SECTION 9 – HEALTH AND SAFETY POLICIES
APPENDIX C
I have read and received the School of Dentistry's Worker's Right to Know Hazard
Communication package. I have also participated in or viewed my department or unit's
Hazard Communication Program.
I understand my rights to a safe work place.
Signature
______________________________
Name (please print)
Date
SECTION 9 – HEALTH AND SAFETY POLICIES
SECTION 9 – HEALTH AND SAFETY POLICIES
III.
INJURY AND ILLNESS PREVENTION PROGRAM
A. Facility Name: University of California, San Francisco School of Dentistry (at all its
sites)
B. Date of Preparation: April 2000, reviewed and updated March, 2011
C. Purpose of this Plan
4. The purpose of this written Injury and Illness Prevention Program (IIPP) is to
provide a comprehensive plan for the School of Dentistry to complement the
IIPP for the UCSF campus (copy of campus plan attached).
5. The School of Dentistry is committed to maintaining a safe environment for its
students, faculty, staff, patients, and visitors. The School encourages all of its
constituencies to communicate about occupational and environmental health
and safety matters without fear of reprisal.
D. Responsibilities
6. The School Health & Safety Director (in consultation with the Health & Safety
Policy Committee), the Department Management Services Officers, and Clinic
Directors are responsible for the implementation of the general program.
7. The School Health and Safety Director (in consultation with the Health &
Safety Policy Committee), Department Management Service Officers, and
Clinic Directors are responsible for the maintenance of the Bloodborne
Pathogens Plan of the Program. Specific personnel instructions and
procedures for this plan are contained in the separate UCSF School of
Dentistry Bloodborne Pathogens Exposure Control Plan.
8. The School Health & Safety Director (in consultation with the Health & Safety
Policy Committee), the Department Management Services Officers, and Clinic
Directors are responsible for the maintenance of the Hazard Communication
Plan of the Program. Specific employee instructions and procedures for this
plan are contained in the separate UCSF School of Dentistry Hazard
Communication Program.
i. The School Health & Safety Director (in consultation with the
Health & Safety Policy Committee), the Department Management
SECTION 9 – HEALTH AND SAFETY POLICIES
Services Officers, and Clinic Directors are responsible for the
maintenance of the Fire and Emergency Plan of the Program.
Specific personnel instructions and procedures for this plan will
be contained in the separate UCSF School of Dentistry
Emergency Action Plan.
ii. The School Health & Safety Director (in consultation with the
Health & Safety Policy Committee), the Department Management
Services Officers, and Clinic Directors are responsible for the
maintenance of the General Office Safety Plan of the Program
E. Compliance Methods
iii. To ensure compliance with the school IIPP, the following policies
and procedures are enforced:
1. Personnel compliance with the IIPP is evaluated annually
as a part of their job performance review
2. Personnel who make a significant contribution to the
Program by identifying hazards or improving safe work
practices and engineering controls are recognized by the
responsible parties and/or by having written
acknowledgment placed in his or her personnel file.
3. Personnel who fail to comply with the safe work practices
and procedures of the IIPP are subject to disciplinary
action, including termination of employment under the
format of the school's disciplinary action policy for
personnel
4. Personnel are trained to comply with the IIPP safe work
practices and procedures prior to being placed in the
workplace. After the initial safety training, repetition and
review of safety procedures and policies occur annually
F. Communication Methods
SECTION 9 – HEALTH AND SAFETY POLICIES
iv. The School of Dentistry IIPP requires that personnel report any
perceived hazard to their supervisor upon discovery. Reporting
of possible health or safety hazards is a part of the person's job
description and is a requirement for employment.
v. All personnel are instructed that the reporting of possible hazards
is encouraged and required by school policy. Our school policy
is to encourage and reward the reporting of office hazards, and
personnel should not fear any reprisal for such reporting
vi. Our school communication system for health and safety issues is
the following:
1. Personal instructions. Personnel are given personal
instructions about hazards and safety requirements prior
to job assignment and thereafter, ongoing, as the need
occurs.
2. Staff meetings. Health and safety issues are a permanent
agenda item for these meetings.
3. Specific memoranda. Written instructions are provided to
personnel as necessary to ensure that specific hazards
and methods of avoiding them are understood. The
written memorandum also serves as a reminder of the
hazard or safety requirement
4. Health and Safety policies and manuals. These include
the Bloodborne Pathogens Exposure Control Plan, Hazard
Communication Program, Emergency Action Plan, , and
Radiation Safety Manual. The Chemical Hygiene Plan,
Biosafety Manual and Chemical Safety Manual are
available at the link at the end of this document, 9.40
5. Safety committee meetings. These include the Health &
Safety Policy Committee, which is chaired by the Dean,
and the Health & Safety Operations Committee
SECTION 9 – HEALTH AND SAFETY POLICIES
6. Material Safety Data Sheets (MSDS)
7. Posters and signs
8. Warning labels
G. Hazard Identification
vii. Procedures for identifying and evaluating workplace hazards
include the following:
1. Ongoing review and discussion of Cal/OSHA standards
that identify hazardous activities and prescribe how safety
is assured by members of the Health & Safety Policy
Committee, and other groups
2. Ongoing review and discussion of research literature and
available published statistics on occupational accidents
and illnesses in dentistry and research laboratories by the
above groups
3. Participation in the campus wide Health Policy Board and
the Chancellor’s Occupational Health Steering Committee
4. Observation of work practices, work areas, and
equipment, looking for obviously or potentially unsafe
conditions
5. Investigation of accidents, injuries, illnesses, near misses,
and unusual occurrences
6. Evaluation of worker safety suggestions or complaints
7. Inspections and evaluations are made whenever new
substances, processes, procedures, or equipment are
introduced into the workplace to determine if an
occupational hazard exists and how to avoid or eliminate
such hazards
8. Formal scheduled inspections for hazardous chemical
conditions are conducted once a year or as needed by the
SECTION 9 – HEALTH AND SAFETY POLICIES
campus Environmental Health & Safety Department
(EH&S).
9. Formal monitoring by industrial hygienists from the
campus EH&S is conducted on an as-needed basis
H. Investigation
viii. All occupational injuries or illnesses are investigated by the
School Health & Safety Director, Department Management
Services Officers, or Clinic Directors. The investigation's
objective is to determine the facts that led to the accident and not
to assign blame. After the facts are assembled, the administrator
evaluates the cause and determines why the accident happened
and what can be done to prevent similar accidents in the future
ix. All accidents are reported on a School of Dentistry Incident
Report form. Employee Health handles medical monitoring.
Insurance and Risk Management prepares, posts, and maintains
the OSHA Log 200. Blood and body substance exposures are
also handled by Employee Health and through the campus
needlestick hotline
I. Correction
x. The school policy is to eliminate all hazards and unsafe work
practices immediately. If the hazard cannot be corrected upon
discovery, personnel are instructed on how to avoid or protect
themselves from the hazard or are removed from the hazardous
site
J. Training
xi. All employees are required to read this policy and complete the
Specific Job Site Hazard Safety Information questionnaire
(Appendix D), to be reviewed with the employee's supervisor.
Both the employee and the supervisor must sign the form. The
SECTION 9 – HEALTH AND SAFETY POLICIES
signed formed will be maintained in the employee's personnel
file.
xii. All new personnel are trained for hazards that may occur while
performing their assigned work duties.
xiii. All personnel are trained before starting new job assignments or
duties, unless their previous training covers the new work
assignment.
xiv. All personnel are trained whenever new substances, processes,
procedures, or equipment are introduced into the workplace and
represent a new hazard.
xv. Safety training is given whenever the employer is made aware of
a new or previously unrecognized hazard.
xvi. Supervisors or the designated safety personnel are trained to
know and understand those safety and health hazards to which
personnel under their immediate direction and control may be
exposed.
K. Record Keeping
xvii. Records of scheduled and periodic inspections to identify unsafe
conditions and work practices include the person(s) conducting
the inspection, the identified unsafe condition, and action taken
to correct the condition or practice. Records must be maintained
for three years.
xviii. Personnel records of health and safety training are kept as
required by the seven mandated sections of 3203. Records must
include:
1. Trainee name
2. Training dates
3. Types of training
4. Training providers
SECTION 9 – HEALTH AND SAFETY POLICIES
xix. These records are required to be kept for three years, except for
personnel who have worked for less than one year, provided that
the employer gives the records to the person upon termination of
employment.
xx. *See Table I of UCSF Campus Injury and Illness Prevention
Program for a more comprehensive list of record-retaining
departments.
SECTION 9 – HEALTH AND SAFETY POLICIES
APPENDIX D
UC San Francisco
School of Dentistry
SPECIFIC JOB SITE HAZARD SAFETY INFORMATION
Name of Employee____________________________________________________
Work Site Location____________________________________________________
The following items must be filled in by the employee prior to signing this document. Please take the time to fill in the
answers carefully. If a question is not applicable to your particular work site, write N/A. Your supervisor must review
this document prior to signing it.
1. Who do you call in case of a chemical spill and what is the phone number? (See Hazard Communication Program)
__________________________________________________________________________________________
2. What is the phone number of the police department in case of an emergency? (See campus directory)
__________________________________________________________________________________________
3. What is the non-emergency phone number for the police department? (See campus directory)
__________________________________________________________________________________________
4. Location of the eyewash station:
__________________________________________________________________________________________
5. Location of the emergency shower:
__________________________________________________________________________________________
6. Location of the first aid kit(s):
__________________________________________________________________________________________
7. Location of flashlights:
__________________________________________________________________________________________
8. Location of fire extinguisher(s):
__________________________________________________________________________________________
9. Location of all fire exits in your work site:
SECTION 9 – HEALTH AND SAFETY POLICIES
__________________________________________________________________________________________
10. Location of the nearest chemical spill cabinet:
__________________________________________________________________________________________
11. Where are the Material Safety Data Sheets (MSDSs) kept? (See Hazard Communication Program)
__________________________________________________________________________________________
12. How do you dispose of sharps (e.g., needles)? (See Bloodborne Pathogens Exposure Control Plan)
__________________________________________________________________________________________
__________________________________________________________________________________________
13. How do you dispose of hazardous chemical wastes, such as radioactive materials or carcinogenic compounds? (See Hazard
Communication Program)
__________________________________________________________________________________________
__________________________________________________________________________________________
___________________________________________________________________________________________
14. How do you dispose of biohazardous waste? (See Bloodborne Pathogens Exposure Control Plan)
___________________________________________________________________________________________
___________________________________________________________________________________________
__________________________________________________________________________________________
15. List the hazards (biohazardous, as well as chemical hazards) in your particular workplace and the safety equipment provided
Section 9.for your use in the handling of these materials:
___________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I have discussed with my supervisor the emergency procedures and safety information pertinent to my particular work site
and duties.
________________________________________
____________________________________
Signature of Employee
Date
I have reviewed the above information with my employee and certify that it is accurate and complete.
SECTION 9 – HEALTH AND SAFETY POLICIES
________________________________________
______________________________________
Signature of Supervisor
Date
SECTION 9 – HEALTH AND SAFETY POLICIES
SECTION 9 – HEALTH AND SAFETY POLICIES
UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
INJURY AND ILLNESS PREVENTION PROGRAM
For Compliance With
California Code of Regulations
Title 8, Section 3203
SIC Code 8221
INQUIRIES SHALL BE DIRECTED TO:
OFFICE OF ENVIRONMENTAL HEALTH & SAFETY
50 MEDICAL CENTER WAY
SAN FRANCISCO, CA 94143-0942
PHONE: 476-1300 / FAX: 476-0581
Implemented July 1991
SECTION 9 – HEALTH AND SAFETY POLICIES
I.
Introduction
The purpose of this written Injury and Illness Prevention Program (IIPP) is to
provide a comprehensive plan demonstrating the integration of the requirements
of California Code of Regulations, Title 8, section 3203 into ongoing health and
safety compliance activities at the University of California, San Francisco (UCSF).
This written program also reinforces the University of California’s Systemwide
Policy on Health, Safety, and Environmental Protection, and incorporates this
Policy by reference.
California Senate Bill 198 (SB 198), passed by the legislature in 1989, expanded
the Injury and Illness Prevention Program requirements stated in the General
Industry Safety Orders, California Code of Regulations, Title 8, section 3203. This
written IIPP was prepared to conform to the requirements of the implementing
legislation and the standards adopted by the Cal/OSHA Standards Board in
January 1991.
A. University of California Systemwide Policy Statement
The University of California is committed to maintaining a safe environment
for its students, academic appointees, staff, visitors, and members of the
general public. Further, it is dedicated to minimizing the impact of its
operations on the environment surrounding its campuses and laboratory
sites.
SECTION 9 – HEALTH AND SAFETY POLICIES
The University has a commitment to promote effective loss reduction and
loss prevention measures for the University’s property and casualty
exposures. Based on recognized principles and published standards of
environmental protection, academic excellence, fiscal responsibility, and
public service, the University will promote comprehensive injury and illness
prevention, as well as hazardous materials and environmental
management programs in an atmosphere that encourages employees,
students, and other campus members to communicate about occupational
and environmental health and safety matters without fear of reprisal.
It is the policy of the University to conduct its operations in conformance
with applicable laws, regulations, and relevant published standards and
practices for health, safety and environmental protection.
B. Responsibilities
1.
Chancellors and Laboratory Directors are responsible for ensuring
the implementation of the Policy on Health, Safety and
Environmental Protection at all facilities under their control.
2.
Vice Chancellors, and Deputy and Associate Laboratory Directors
are responsible for implementing the Policy in all facilities within
their respective jurisdictions.
3.
Deans, Directors, Department Heads, Principal Investigators, and all
other managers and supervisors are responsible for compliance with
this Policy as it relates to operations under their control and in
carrying out their day-to-day responsibilities.
SECTION 9 – HEALTH AND SAFETY POLICIES
4.
All employees, students, and other campus members are
responsible for adherence to this Policy in carrying out their day-today responsibilities.
II.
Implementing Authorities and Responsible Parties at the University of California,
San Francisco (UCSF)
The authority and responsibility for the overall implementation and maintenance of
the Injury and Illness Prevention Program (IIPP) in accordance with University of
California Systemwide Policy and the California Code of Regulations, Title 8,
section 3203 has been delegated to the Director of the Office of Environmental
Health and Safety (OEH&S). In order to build an effective IIPP, it must be
integrated throughout the entire Medical Center and Campus. As each
organizational unit must share in the implementation and maintenance of the IIPP,
supporting responsibilities are assigned to them.
A. Campus – Wide
At the University of California, San Francisco (UCSF), the authority and
responsibility for the overall implementation and maintenance of this
program in accordance with University of California Systemwide Policy and
California Code of Regulations, Title 8, section 3203 has been delegated to
the following individual:
Name: Robert Eaton, MS, CIH, CHMM, CSP, REHS
Title: Director, Office of Environmental Health and Safety (OEH&S)
Signature: ________________________________________________
SECTION 9 – HEALTH AND SAFETY POLICIES
Description of Authority and Responsibility Related to the Campus - Wide
Implementation of this program.
1. Overall oversight of Health and Safety Programs.
2. Implementation of UCSF Health and Safety Policies.
3. Liaison with oversight Committees and Regulatory Agencies.
4. Identification of hazards and implementation of preventive measures.
5. Advise the Chancellor and the Campus of appropriate health and safety
requirements.
The Director of OEH&S has designated the OEH&S Department Safety
Advisors (DSAs) to assist individual departments or units on UCSF campus
to implement this IIPP.
B. Medical Center
The authority and responsibility for the implementation and maintenance of
the IIPP for the Medical Center and the Hospitals, in accordance with
University of California Systemwide Policy and California Code of
Regulations, Title 8, section 3203 is held by the following individuals:
Name: Matthew Carlson, MPH CIH
Title: Medical Center Safety Officer
Description of Authority and Responsibility Related to the Medical Center
and Hospital Implementation of the IIPP.
1. Implementation of safety standards in hospital areas.
SECTION 9 – HEALTH AND SAFETY POLICIES
2. Monitoring of individual department managers.
3. Liaison with Oversight Committee and regulatory agencies
4. Identification of hazards and implementation of preventive measures
5. Advise the Chancellor and the Medical Center of appropriate health and
safety requirements.
C. Langley Porter Psychiatric Institute (LPPI)
The authority and responsibility for the implementation and maintenance of
the IIPP for Langley Porter Psychiatric Institute, in accordance with
University of California Systemwide Policy and California Code of
Regulations, Title 8, section 3203 is held by the following individuals:
Name: Esther Lam
Title: LPPI Facilities, Health and Safety Manager
Description of Authority and Responsibility Related to Langley Porter
Psychiatric Institute Implementation of the IIPP.
1. Implementation of safety standards in hospital areas.
2. Monitoring of individual department managers.
3. Liaison with Oversight Committee and regulatory agencies
4. Identification of hazards and implementation of preventive measures
5. Advise the Chancellor and the Campus of appropriate health and safety
requirements.
D. Operational Units and Departments
SECTION 9 – HEALTH AND SAFETY POLICIES
Operational units such as departments, or schools or research institutes
will establish their individual IIP as directed by the Vice Chancellors.
The authority and responsibility for the implementation and maintenance of
the IIPP for Operational Units and Departments, in accordance with
University of California Systemwide Policy and California Code of
Regulations, Title 8, section 3203 is held by the following individuals:
Name: __________________________________________________
Department/Title: _________________________________________
Signature: ________________________________________________
Description of Authority and Responsibility Related to Operational Units
and Departments Implementation of the IIPP.
1. Implementation of safety standards in administrative and laboratory
areas.
2. Monitoring of individual department managers and Principal
Investigators.
3. Liaison with Oversight Committee and regulatory agencies.
4. Identification of hazards and implementation of preventive measures.
5. Advise the Chancellor and the Campus of appropriate health and safety
requirements.
III.
Effective Communications With Employees Have Been Established Using the
Following Methods:
SECTION 9 – HEALTH AND SAFETY POLICIES
The University of California, San Francisco, and (UCSF) uses the following
methods to ensure effective safety communication:
A. The Office of Environmental Health and Safety (OEH&S) provides support and
resources to Administrative Units to meet training and information requirements.
OEH&S reviews and approves all safety training programs and information
materials. Campus and Medical Center safety committees develop appropriate
training programs and materials in conjunction with OEH&S. OEH&S and
Administrative Units are required to implement the training function.
B. Forms of employer-to-employee communications on health and safety topics
include:
1. Program Documents
a. Chemical Hygiene Plan
b. Hazard Communication Program
c. Fire Plans
d. Emergency Action Plans
2. Safety Manuals
a. Campus Manuals
i. Biosafety Manual
ii. Chemical Safety Manual
iii. Radiation Safety Manual
iv. Controlled Substances Program Manual
v. Respiratory Protection Manual
vi. Construction Safety Manual
vii. Fire Protection Program Manual
viii. Formaldehyde Program Manual
SECTION 9 – HEALTH AND SAFETY POLICIES
b. Medical Center Manuals
i. Infection Control
ii. Environment of Care Manual
iii. Radiation Protection Handbook
iv. Medical Center Emergency and Disaster Procedures Manual
v. Refer to the following Link for additional Medical Center Manuals:
http://manuals.ucsfmedicalcenter.org/
3. OEH&S Newsletters and Bulletins
4. Safety Committee Meetings
5. Material Safety Data Sheets (MSDSs)
6. Posters and Signs
7. Warning Labels
8. New Employee Safety Orientation and Ongoing Safety Training
C. The following methods are available, as necessary; to ensure that health and
safety communications are readily understandable by all affected employees:
1. Multilingual translators/trainers
2. Sign language
D. Employees are encouraged to bring to UCSF’s attention any potential health or
safety hazard that may exist in the work area. UCSF provides an Employee
Safety Suggestion/Hazard Report; employees may also communicate safety
concerns to OEHS directly by phone.
Employees are advised there will be no reprisals or other job discrimination for
expressing any concern, comment, suggestion or complaint about a safety-related
matter. Employees may file the Employee Safety Suggestion/Hazard Report form
anonymously.
SECTION 9 – HEALTH AND SAFETY POLICIES
E. Employees are expected to follow UCSF and legal health and safety
standards. Adherence to safe work practices and the proper use of required
Personal Protective Equipment will be monitored. Compliance will be reinforced
by Supervisors and Principal Investigators. Non-compliance will be addressed
through Personnel procedures, including progressive discipline and performance
evaluations. Specific procedures are referenced in the UCSF Personnel Policies
for Staff Members Manual, and union contracts.
IV. Compliance with Health and Safety Standards
Supervisors and principal investigators are required to inform employees of the
provisions contained in their IIP Program. Employees are expected to follow
UCSF and legal health and safety standards. Adherence to safe work practices
and the proper use of required personal protective equipment will be monitored.
Compliance will be evaluated and reinforced by supervisors and principal
Investigators. Non-compliance will be addressed through personnel procedures,
including progressive discipline and performance evaluations.
In addition, it is the supervisor’s responsibility to provide training to workers whose
safety performance is deficient. Specific procedures are referenced in the UCSF
Personnel Policies for Staff Members Manual, and union contracts.
V. Responsibilities With Regard to Maintaining Training Records, Inspection
Records, and Files of Safety Information are Designated as Follows and are
Summarized in Table I:
A. Office of Environmental Health and Safety (OEH&S)
SECTION 9 – HEALTH AND SAFETY POLICIES
1. OEH&S maintains a master electronic file of Material Safety Data Sheets
(MSDSs). MSDSs are available for campus and medical center departments.
2. A database of training records is maintained by OEH&S. All classroom
training is to be documented and entered into the OEH&S database. Online
training records are electronically stored in the database
3. OEH&S maintains inspection records for radiation safety, biological safety,
fire and life safety, physical safety, asbestos control, and chemical laboratory
safety, buildings and grounds, etc. OEH&S also maintains records of particular
hazard inspections and environmental measurements performed by OEH&S.
B. Medical Center and Langley Porter Administration also maintain health
and safety inspection records independent of OEH&S.
C. Occupational Health Program maintains medical monitoring records as
required by regulation.
D. Disability Management Services - Workman’s Compensation Unit
prepares and maintains the Cal-OSHA Form 300 and the Employer's First
Report of Injury. UCSF's third party administrator, Octogon Risk Services is
the agent responsible for maintaining Worker's Compensation claim files.
SECTION 9 – HEALTH AND SAFETY POLICIES
TABLE I
INJURY AND ILLNESS PREVENTION RECORDKEEPING
UNIVERSITY OF CALIFORNIA, SAN FRANCISCO (UCSF)
RECORD
RETENTION
PERIOD
OEH&S
Cal-OSHA Form 300
5 Years
No
Employer First Report of Injury
5 Years
No
Accident Investigations
3 Years
No
Worker’s Compensation Claims
Medical Surveillance Records
Safety Committee Minutes
Worksite Inspection Forms
Employee Safety Suggestion/Hazard
Report Form
Material Safety Data Sheets
Exposure Monitoring
Employee Training
Cal-OSHA Inspection Reports
Emergency Response Forms
Community Environmental Monitoring
Permanent
Permanent
3 Years
3 Years
3 Years
No
No
Yes
Yes
Yes
Permanent
Permanent
3 Years
3 Years
Permanent
5 Years
Yes
Yes
Yes
Yes
Yes
Yes
DEPARTMENT RETAINING RECORD
OTHER (SPECIFY)
Disability Management Services Workman’s Compensation Unit
Disability Management Services Workman’s Compensation Unit
Disability Management Services Workman’s Compensation Unit
Sedgwick CMS
Occupational Health Program
Available On-Line
VI Safety Committees
The University of California, San Francisco (UCSF) has established safety
committees to address policies and procedures for safe operations and facilities. Two
types of safety committees have been instituted:
• Campus and Medical Center health and safety policy committees to develop
policies and procedures for the safe use, handling, storage and disposal of
hazardous materials; these committees are listed below.
• Interactive management - employee safety committees have been mandated to
enhance communication between employees and management for any health and
safety issue; these committees are discussed below.
SECTION 9 – HEALTH AND SAFETY POLICIES
A. Campus and Medical Center Health and Safety Policy Committees
The policy committees, which are advisory to the Chancellor, are composed of
faculty and staff with expertise in the use and handling of a specific class of
hazardous material (Biological, Chemical, and Radiological). The committees are
responsible, in collaboration with the Office of Environmental Health and Safety
(OEH&S), for recommending to the Chancellor health and safety policy and
procedures for the use, handling, storage and disposal of hazardous materials. In
addition, they arbitrate disagreements on work practices and procedures and
make recommendations to the Chancellor regarding those who fail to comply with
established health and safety standards. The committees are listed below
1. Campus Safety Committees
a. Radiation Safety Committee
b. Chemical and Environmental Safety Committee
c. Institutional Biosafety Committee
d. OEH&S User Advisory Committee
e. Laboratory Managers Steering Committee
f. Hazards Emergencies Response and Recovery Committee
g. Health and Safety Policy Committee
h. Chancellor’s Steering Committee on Nuclear, Biological and Chemical
Terrorism (BCT) Committee
i. Emergency Planning Bioterrorism and Communicable Disease
Committee (BCDC)
2. Medical Center Committees
a. Infection Control Committee
b. Medical Center Environmental of Care Committee
SECTION 9 – HEALTH AND SAFETY POLICIES
c. Medical Center Emergency Planning, Bioterrorism, and Communicable
Disease Committee
d. Committee on Mass Casualty Incidents (Comcit)
B. Operational entities that choose to implement safety committees will use the
following method. Establishment of a safety committee is recommended.
UCSF has mandated interactive management - employee safety committees to
address unsafe operations and areas. These safety committees facilitate the
communication of health and safety issues to and from employees.
Schools and departments are expected to either establish interactive
management - employee safety committees or delegate safety committee
responsibilities (which are discussed below) to existing committees. These
committees assist in implementing general safety standards and the policies and
procedures developed by the Campus and Medical Center health and safety
policy committees. Interactive management - employee safety committees are
expected to:
1. Meet regularly, not less than quarterly.
2. Prepare and make available to employees minutes of committee meetings
reporting on health and safety issues discussed at the meetings. UCSF
provides an example reporting form in Appendices C and C-1.
3. Review results of selected periodic, scheduled inspections.
4. Review OEH&S investigations of occupational accidents and incidents
related to injury and illness, as appropriate.
5. Review OEH&S investigations of alleged hazardous conditions brought to
the attention of any committee member.
6. Submit recommendations to assist in the evaluation of employee safety
suggestions.
SECTION 9 – HEALTH AND SAFETY POLICIES
7. With assistance from OEH&S, establish policies that govern the abatement
actions taken to correct hazards or deficiencies.
VII Hazard Evaluation and Correction
Hazard evaluation and control is the heart and soul of an effective injury and illness
prevention program. Periodic inspections and correction and control procedures provide
a method of identification, elimination and control of existing or potential hazards in the
workplace. The hazard evaluation and control system is also the basis for developing
safe work procedures, and injury and illness prevention training.
OEH&S is responsible for performing a variety of hazard audits. These include hazard
evaluations, facility or worksite inspections, accident investigations and exposure
monitoring. These audits are conducted routinely, as needed, or in response to specific
requests. Table II shows the audit schedule. In addition to the routine audit schedule,
whenever a new radioactive or biohazardous substance process, procedure or
equipment is introduced into the workplace, a department safety advisor from OEH&S
should be invited to inspect the workplace to assess any potential associated hazards
and work with the laboratory to determine what control processes are needed to mitigate
those hazards. The laboratory supervisor or principal investigator is responsible for
implementing the necessary control processes recommended by the department safety
advisor.
Hazard Correction:
The conditions observed or evaluated are compared with occupational safety and health
standards, predetermined agreement with regulatory agencies, or current good practice.
Once identified and evaluated, hazards shall be corrected as promptly as possible. For
those that can’t be immediately corrected, an action plan should be developed based on
the probability and severity of an injury, illness, or property damage that would result
SECTION 9 – HEALTH AND SAFETY POLICIES
from the hazard. Interim protection for employees may have to be implemented until the
hazard is abated. OEH&S coordinates corrective actions and interim protection, if
needed, with responsible departments and effected employees as appropriate.
VIII Investigation of Accidents and Occupational Injuries/Illnesses
Upon receipt from Disability Management Services - Workman’s Compensation Unit of a
Supervisor Report of Injury Form (SR1), OEH&S will evaluate the report and perform
investigations as appropriate. The investigation records are maintained by OEH&S.
Copies are filed in the department in which the accident or injury or illness took place
and at the Disability Management Services - Workman’s Compensation Unit office.
IX Injury and Illness Prevention Program (IIPP) Training
A. Injury and Illness Prevention Program (IIPP) training, covering both general safe work
practices and job specific hazard training, is provided according to the following criteria:
1. Supervisors are provided training to familiarize them with the safety and health
hazards to which employees under their immediate direction and control may be
exposed. At the University of California, San Francisco (UCSF), this training is
provided through online training or by qualified individuals from OEH&S.
2. New employees are trained in general safe work practices and campus policy
and procedures through online training or by qualified individuals from OEH&S.
Job specific hazard training is provided by their departments.
3. All employees given new job assignments are provided appropriate training by
qualified individuals from the affected departments and/or OEH&S.
4. All employees working with hazardous materials are trained by OEH&S.
SECTION 9 – HEALTH AND SAFETY POLICIES
5. Whenever new substances, processes, procedures or equipment, which
represent a new hazard, are introduced to the workplace; affected employees will
then be trained by qualified individuals from their department and/or OEH&S.
6. Whenever the campus is made aware of a new or previously unrecognized
hazard, OEH&S will evaluate the hazard and determine appropriate control
actions. Then affected employees will be trained by qualified individuals from their
department and/or OEH&S.
B. OEH&S is available to assist with the development and review of new departmental
safety programs. In addition, OEH&S should be contacted to review existing
departmental safety programs. OEH&S may be contacted to conduct training or to
provide training materials (videotapes, slides, handouts, etc.). Training may include, but
is not limited to, the following topics:
1. Injury and Illness Prevention Program
2. Hazard Communication
3. Emergency Action Plan
4. Fire Safety
5. Equipment Operation
6. Radiation Safety
7. Biological Safety
8. Chemical Safety
9. Physical Safety
10. Hazardous Waste Materials Handling and Disposal (Chem., Rad., Bio.)
SECTION 9 – HEALTH AND SAFETY POLICIES
C. All training will documented using the Office of Research Training Attendance
Form. OEH&S maintains a training records database.
D. UCSF Schools, Departments, and Units are encouraged to periodically conduct selfevaluations of their IIPP.
SECTION 9 – HEALTH AND SAFETY POLICIES
IV.
TUBUERCULOSIS EXPOSURE CONTROL PLAN
Policy & Purpose
It is the policy of the UCSF School of Dentistry to provide dental care, when
necessary, to patients with tuberculosis (TB), in a manner that minimizes
the risk of transmission of TB to others.
Early diagnosis, timely and
effective treatment of individuals with active pulmonary TB, effective use of
administrative, work practice, and engineering controls, the use of
respiratory
protection,
and
a
comprehensive
health
care
worker
surveillance program are key components of this policy.
The School of Dentistry Tuberculosis Exposure Control Plan is intended to
serve as the guidance document for preventing occupational transmission
of tuberculosis.
The policies and procedures in the document are
consistent with the current recommendations from the Centers for Disease
Control and Prevention (CDC, 1993) and Cal/OSHA compliance guidelines
(8/1/94 and 7/10/95).
Scope
The policies and procedures in this Tuberculosis Exposure Control Plan are
applicable to all School of Dentistry personnel who potentially have contact
with patients with infectious tuberculosis, including employees, faculty,
students, patients, and visitors.
Responsibility
SECTION 9 – HEALTH AND SAFETY POLICIES
Overall
The School of Dentistry Health & Safety Policy Committee, chaired by the
Dean, will have responsibility for the establishment, implementation, and
oversight of this plan.
Individual
The individual employee or student is responsible and accountable for
compliance with this document and, therefore, compliance with the
guidelines and legal standards used to formulate this plan.
Departmental
Each department/unit manager is responsible for incorporating the relevant
aspects of this plan into departmental/unit policies and procedures and will
have the responsibility for ensuring implementation of the plan where
applicable.
Risk Assessment
TB control measures for the School of Dentistry will be based on a careful
assessment of the risk of TB transmission in the various School of
Dentistry clinical settings. The purpose of this assessment is to evaluate
the risk of transmission in each area and occupational group so that
appropriate infection control interventions can be developed based on
actual risk.
The risk assessment shall be conducted by the Health &
SECTION 9 – HEALTH AND SAFETY POLICIES
Safety
Policy
Committee
with
input
as
needed
from
hospital
epidemiologists, infectious disease and pulmonary disease specialists,
infection control practitioners, occupational health personnel and industrial
hygienists, engineers, clinic administration, department/unit managers, and
public health authorities.
Surveillance of Care Providers
All School of Dentistry personnel with patient contact will participate in the
surveillance program.
These groups will include, but not be limited to
School of Dentistry care providers, dental residents and students, dental
faculty with clinical responsibilities, dental hygiene personnel and trainees,
clinic staff, and contract employees.
Surveillance of students will be
carried out by Student Health Service. Surveillance of employees will be
carried out according to approved Occupational Health procedures and the
School of Dentistry Tuberculosis Exposure Control Plan. Accountability for
documenting this surveillance for each group will be assigned to the
appropriate School of Dentistry employee. Employee Health personnel will
maintain surveillance using established procedures for School of Dentistry
employees, which Occupational Health will present to the Health and
Safety Policy Committee on an annual basis.
This report will give
surveillance results for each area or department and should include:
The number of employees in the department, clinic, or other facility
The number of employees evaluated (skin test or questionnaire)
The rate of compliance
The number who were previously skin test-negative
SECTION 9 – HEALTH AND SAFETY POLICIES
The number of documented conversions
The conversion rate
The number who were previously skin test-positive
The number of positive individuals screened for symptoms
The number of individuals found to have active disease
Occupational Health will maintain a confidential database of surveillance
information. Groups to be screened annually and every six months shall
be defined by the Health & Safety Policy Committee based on surveillance
data, assessed risk and input from infectious disease and pulmonary
disease specialists, infection control practitioners, and public health
authorities.
Unprotected exposure to patients with infectious TB must be reported to the
Health & Safety Policy Committee by any individual who suspects such
exposure. Follow-up will be carried out as described in the tuberculosis
exposure control plan.
Problem Evaluation
A problem is defined as:

Suspected patient-to-School of Dentistry personnel, School of Dentistry
personnel transmission to patients or others, or patient-to-patient transmission;

Greater-than-5% conversion rate in one area or department in a surveillance
period (one year); or
SECTION 9 – HEALTH AND SAFETY POLICIES

A conversion rate for one or more areas or departments that is significantly
higher than for other departments;
Evaluation may include, but is not limited to:

Administrative controls, such as institution of policies regarding referral of
patients for assessment and treatment of TB prior to dental treatment;

Engineering controls;

Other precautions in the treatment of patients considered to be at high risk of
having infectious TB at the time of treatment; and

Compliance with infection control practices.
Patient Care Issues - Screening for TB
Early detection and identification of suspect TB cases by careful review of the
patient's medical history is the key to preventing the transmission of TB.
The medical history should be reviewed for the following symptoms:

unexplained persistent cough

undiagnosed pneumonia in a patient at risk or pneumonia that is unresponsive
to conventional antibacterial treatment

pneumonia in a patient who has had recent contact with an active case

unexplained fever, night sweats, anorexia, and weight loss

readmission of or outpatient follow-up visit for patient recently diagnosed with
TB

patients who are currently taking or have recently taken antibiotic treatment for
TB, including the following:
SECTION 9 – HEALTH AND SAFETY POLICIES

Isoniazid (INH)

Rifampim (RIF)

Pyrazinamide (PZA)

Ethambutol (EMB)

Streptomycin (SM)

Ethionamide (ETH)

Cycloserine (CS)

Paraaminosalicylic Acid (PAS)

Capreomycin (CM)

Kanamycin (KM)

Amikacin (AK)
A high index of suspicion should be maintained for populations receiving
specialized care, such as:

clinics providing care to HIV-infected populations

patients admitted to special programs, such as long-term care (psychiatric,
domiciliary, jail/prison, or other congregate living)

substance abuse (inpatient and outpatient)

homeless population
Patient Care Issues - Referrals and Commencing with Dental Treatment
In areas where patients with undiagnosed tuberculosis (TB) may be present,
an individual with symptoms of TB should be managed in a manner that
minimizes risk of transmission.
SECTION 9 – HEALTH AND SAFETY POLICIES

Waiting areas should have ventilation that provides greater than six air
changes per hour (ACH).

Coughing patients should be instructed to effectively cover their coughs with a
handkerchief, tissue, or surgical mask. Signs with this request (nonverbal/pictograph or in several languages) should be prominently posted.
Tissues and masks should be readily available in waiting areas.

Patients with symptoms suggestive of TB should be removed from common
waiting areas as soon as possible and be placed in a private exam room with
the door closed to await evaluation. If the patient is suspected or known to
have infectious TB, the room must remain vacant for one hour after the patient
leaves if the patient was unable to remain masked for the majority of the stay.

The HCW who shares air space (e.g., exam room) with an unmasked patient
must wear a particulate respirator designated N-95, P-95, or R-95. (See section
entitled “Particulate Respirators”)

The possibility of TB as a diagnosis will be communicated to other departments
prior to transport of the patient to those departments.
The following protocols should be followed if medical history reveals TB
symptoms or treatment:
 In cases where a patient's medical history reveals TB symptoms and dental
treatment can be delayed (most common occurrence), patients should be
referred to their health care provider prior to beginning dental treatment. The
SECTION 9 – HEALTH AND SAFETY POLICIES
dental care provider should consult with the patient's health care provider to
ensure that the patient does not have infectious TB prior to commencing
treatment.
 In cases where the medical history reveals the patient has recently taken
antibiotics for TB and dental treatment can be delayed, consult with the
patient's health care provider to ensure the patient does not have infectious TB
prior to commencing dental treatment.
 In cases where infectious TB is known or suspected and the patient has an
extreme dental emergency requiring treatment, dental care must be provided
using full respiratory precautions for TB (see section on respiratory precautions
for TB during emergency dental treatment) in the appropriate hospital operating
room or SurgiCenter setting.
 “Extreme dental emergency” is defined here as a life-threatening condition
(e.g., extreme swelling affecting the airway, severe bleeding. etc.).
Respiratory Precautions for TB During Emergency Dental Treatment
Because TB is transmitted by the respiratory route, TB control must
emphasize decreasing droplet nuclei at the patient source and minimizing
inhalation of droplet nuclei by those individuals that share the air space
with the infectious patient.
"Respiratory precautions" will be used when active pulmonary/laryngeal TB is
diagnosed or suspected and treatment must be provided for extreme
dental emergencies.
This includes patients with persistent or recurrent
SECTION 9 – HEALTH AND SAFETY POLICIES
symptoms and those whose duration of drug therapy has been inadequate
to render the individual non-infectious.
Elements of Respiratory Precautions for TB:
 The Room
-
treatment will be provided in a hospital or SurgiCenter operating room
-
negative pressure with a minimum of six air changes per hour (ACH)
and HEPA filtration of local exhaust when utilized
-
"Respiratory Precautions" signage
-
handling of trash, linen, soiled equipment, and the performance of
housekeeping duties according to the Bloodborne Pathogens Exposure
Control Plan
 Patient Issues
-
patient must wear tight-fitting, well-secured surgical mask (provides a
physical barrier to capture droplets produced during coughing,
sneezing, or talking) when outside the "Respiratory Precautions" room
-
patient education concerning TB transmission and reason for isolation
 Requirements for patient transport/transfer within the facility
-
notification of receiving department/unit of TB diagnosis and required
precautions prior to patient transport
-
patient must wear tight-fitting, well-secured surgical mask during
transport and until returned to a room that fulfills the requirements of
"Respiratory Precautions"
-
individual transporting a masked patient does not need to wear a mask
SECTION 9 – HEALTH AND SAFETY POLICIES
Particulate respirators designated N-95, P-95, or R-95 will be worn by health
care workers in the following situations:
when entering a room where a patient with known or suspected TB is in
respiratory precautions;
when sharing air space, outside of an isolation room, with an unmasked infectious
TB patient;
when entering an isolation room or other air space that has been occupied by an
unmasked source case in the last hour, in the absence of adjunctive
engineering controls (local exhaust ventilation);
 when performing any emergency dental procedure or when in a room in which
an emergency dental procedure is being performed on patient known or
suspected of having infectious TB; or
 in settings where administrative and engineering controls are not likely to
protect individuals from inhaling droplet nuclei (e.g., transporting an unmasked
patient).
Each operating room or SurgiCenter site will have an available supply of
appropriate particulate respirators.
Engineering Controls
SECTION 9 – HEALTH AND SAFETY POLICIES
Hospital and/or SurgiCenter operating rooms meet all current engineering
controls to prevent the spread and reduce the concentration of infectious
TB droplet nuclei. Any treatment of extreme dental emergencies at the
UCSF School of Dentistry must occur in an operating room setting.
Respiratory Protection Program
Introduction
The most effective way to control respiratory hazards is to follow correct work
practice and facility-prescribed engineering controls.
When additional
protection is needed, respiratory protection (mask/respirator) will be used
to further ensure that individuals are not exposed to airborne biohazardous
contaminants.
Responsibilities
The Health and Safety Policy Committee of the School of Dentistry and
Campus Environmental Health and Safety (EH&S) are responsible for
overall administration of this program, with support from Occupational
Health Services and Student Health Services. This includes the following:
Maintenance of the written program (this policy);
Evaluation of exposure to hazards, (e.g., whether respiratory protection is
needed, and if so, what type); and
Monitoring of supervisors' local enforcement of the programs.
SECTION 9 – HEALTH AND SAFETY POLICIES
Providers in operating rooms or SurgiCenter sites are responsible for
administering the program in their work area. This involves the following:
Ensuring that employees are using, inspecting, and storing particulate respirators
properly;
Supervising contract personnel for safe practice; and
Having a sufficient supply of appropriate particulate respirators available at each
clinical site.
Individuals have a responsibility to follow the requirements of this program.
This involves:
Informing Occupational Health Services of personal health problems that could
interfere with the use of respiratory protective equipment;
Using particulate respirators as instructed;
Leaving the area immediately if he or she believes the respirator is malfunctioning
or not providing adequate protection, consistent with patient safety; and
Checking the particulate respirator before each use to ensure that it is clean and
free of damage or alteration and that it forms a tight seal on the face.
Particulate Respirators.
Particulate respirators that have been NIOSH-tested and have received a
letter designation of N, P, or R followed by a number designation of 95 or
99 will be used for respiratory protection against exposure to TB.
A
particulate respirator designated N-95, P-95, or R-95 has a filtration
efficiency of at least 95% for particles having an aerodynamic diameter
SECTION 9 – HEALTH AND SAFETY POLICIES
smaller than one micrometer and thus is acceptable for protection against
TB.
The particulate respirator must be checked for face-piece fit (fit check) in
accordance with OSHA standards and good industrial hygiene practice by
the dental care provider each time he or she puts on the respirator.
Particulate respirators with at least an N-95, P-95, or R-95 rating will be used
in the following situations:
When performing any high-risk procedure or when in a room where a patient is
undergoing any high-risk procedure;
when in an isolation room or isolation enclosure that is occupied or has been
occupied within the past hour by a source case;
when transporting a source case in a vehicle occupied by both the employee and
the source case; and
when in the presence of an unmasked source case.
Selection of Respirators
Only NIOSH/OSHA-approved respirators with a designation of at least N-95,
P-95 or R-95 will be used.
Fit Testing
EH&S will perform qualitative fit testing on the above respirators.
When
appropriate, a quantitative fit test can be performed. EH&S will not perform
SECTION 9 – HEALTH AND SAFETY POLICIES
a fit test on individuals who have facial hair where the respirator touches
the face. Only a hooded, powdered air-purifying respirator (PAPR) that
totally encloses the head and shoulders can be worn in this case.
By the end of the fitting session, the employee will know:
 how to inspect the respirator;
 how to don and adjust the respirator;
 how to perform fit checks;
 how to store the respirator; and
 to return for training, fit testing, and medical surveillance.
Obtaining a Respirator
Individuals who need fit testing for a mask/respirator for TB control must
undergo medical screening and obtain a respirator medical clearance from
Occupational Health Service (885-7580). Each individual must complete a
respiratory medical screening form, which will be reviewed by Employee
Health to determine the employee’s ability to wear a respirator.
Employees
who
report
medical
conditions
(cardiopulmonary
disease,
claustrophobia, etc.) will be seen in Employee Health for a physical
examination and pulmonary function testing.
Individuals who receive respirator medical clearance must then complete
respirator training and be fit tested by EH&S (476-1300).
training must include the following elements:
Respirator
SECTION 9 – HEALTH AND SAFETY POLICIES
Reasons why a respirator is worn in contaminated environments;
Types of respirators used;
Limitations and capabilities of each respirator;
Purpose of the medical screening/examination;
Conditions that prevent a good face seal;
Necessity of wearing the respirator as instructed, without modification;
Reasons why respirators are not to be shared;
Sanitary care of respirator;
Proper way to inspect a respirator;
Proper way to don and fit-check a respirator; and
Proper way to store a respirator.
Respirator Maintenance and Storage
Respirator must be inspected before and after each use to ensure that it is
clean and intact. If it is soiled, distorted, or in disrepair, the disposable
respirator must be replaced. If the outside of this respirator is wet, it should
be discarded.
Although respirators are generally made of materials that do not support
microbial growth, good practice dictates that respirators be stored in a
clean, sanitary, convenient location and in a vented plastic or paper bag, a
container, or a cabinet. A non-functional disposable respirator should be
discarded as regular waste.
Respirator Usage & Storage Time
SECTION 9 – HEALTH AND SAFETY POLICIES
The disposable respirator can be used for days to months, as long as the
respirator remains intact, passes the fit check, and resistance to inhalation
is not significantly greater than baseline.
Program Evaluation
EH&S will periodically perform work area evaluations to ensure that the
Respirator Protection Program is enforced properly by the supervisors.
During the evaluation, EH&S will review and make recommendations on
respirator usage, maintenance, and storage techniques.
Education & Training
The goal is to provide TB education and training to all School of Dentistry
personnel who have potential contact with patients with infectious
tuberculosis, including but not limited to employees, faculty, and students,
in a manner appropriate to their job category, educational level, and
language comprehension.
Initial training must be given upon hire or prior to assignment in areas where
exposure to TB is anticipated and review and update provided annually
thereafter. Attendance at both the initial training and annual updates is
mandatory.
The teaching methods for training sessions must be varied to allow for diverse
audiences, i.e., lecture, videotapes, and computer interactive programs.
Consideration for educational level, language ability, literacy skills, and
SECTION 9 – HEALTH AND SAFETY POLICIES
commonality of participants must be incorporated into each training
session.
Content for training sessions must include, but is not limited to, the following:
 Basic concepts of TB transmission, pathogenesis, and diagnosis
-
differences between latent TB infection and active disease
-
signs and symptoms of TB
-
possibility of reinfection in persons with a positive PPD test
-
identification of individuals at increased risk for TB
 Potential for occupational exposure to infectious TB within the health care
facility
-
prevalence of TB in the community and in the facility
-
ability of the facility to appropriately isolate patients with active TB
-
at-risk situations for exposure to TB
 Exposure control plan/infection control principles, practices, and limitations
-
daily inspection of infectious patients
-
site-specific control measures/limitations of such measures
-
engineering controls
-
employee screening
-
employee health/workers compensation
-
respiratory precautions
-
personal respiratory protection
PPD testing
SECTION 9 – HEALTH AND SAFETY POLICIES
-
purpose
-
significance of a positive result
-
frequency of PPD testing
-
importance of participation in skin testing
-
anergy testing
-
effect of HIV and other medical conditions on the interpretation of the
result
 Principles of treatment
-
preventative therapy
-
therapy for active TB
-
difficulty of treating MDR-TB
 Health care workers' responsibility to prevent transmission of TB to patients
and other health care workers
-
seeking medical evaluation if symptoms that may be due to TB develop
or if PPD test conversion occurs
-
notifying Employee Health if diagnosed with active TB to enable the
appropriate contact investigation
 The immunosuppressed worker
-
higher risk for TB
-
more frequent and rapid development of clinical TB after infection
-
differences in the PPD interpretation and clinical presentation
-
high mortality rate associated with MDR-TB in immunocompromised
health care workers
SECTION 9 – HEALTH AND SAFETY POLICIES
 Confidentiality of health care worker
Employee Surveillance and Management
Purposes
Prevention of tuberculosis transmission from employees to patients and to other
employees.
Accumulation of data on the risks of infection to School of Dentistry personnel.
Aid in the early detection of infection among employees by offering consultation,
treatment, and referral when indicated.
Identification of nosocomial transmission.
Preplacement Tuberculosis Screening
All individuals who may have been in contact with patients or body fluids that
have contracted TB will undergo tuberculosis (TB) screening at the time of
their pre-placement examination.
Tuberculin skin tests (PPDs) will be
administered and the results read and recorded by Occupational Health or
by a designated acting agent.
The guidelines for the pre-placement screening are as follows:
(1)
The individual presents a documented written history or accurate verbal
description of a positive PPD or medical history of TB.
SECTION 9 – HEALTH AND SAFETY POLICIES
If the individual has had a chest x-ray within the last year, a copy of the report will
be obtained for the Occupational Health chart. If the individual has not had a
chest x-ray within the last year or if the results are unavailable, a current x-ray
will be obtained. A symptom review will be performed, and if symptoms are
suggestive of TB, a chest x-ray will be obtained and referral made for
treatment evaluation. For employees with a history of TB, information will be
obtained regarding the age at diagnosis, duration of treatment, medication,
and dose.
(2)
There is no history of PPD, history of prior negative PPD, or the individual is
unable to describe undocumented results of prior positive PPD.
Individuals will have two-step testing performed unless they can document one
negative PPD within the previous two years. In this case, only a single PPD
needs to be administered.
(3)
There is a history of BCG Vaccination.
The history of BCG vaccination will be noted in the Occupational Health chart. If
the individual has a documented past positive PPD or is unable to describe a
positive PPD, proceed as indicated for individuals with documented written
history or an accurate verbal description of a positive PPD or medical history
of TB. If no documentation or description of a positive PPD is available, a
PPD will be placed.
Interpretation of PPDs
SECTION 9 – HEALTH AND SAFETY POLICIES
If two-step testing is performed, only the second test will be used to make a
negative determination. If the first PPD is positive, a second PPD will not
be done.
Five millimeters or more of induration will be considered positive in the
following groups:
 persons who are HIV infected;
 persons with risk factors for HIV infection but whose HIV status is unknown;
 persons who have had close recent contact with an infectious tuberculosis
case;
 persons who have chest x-rays consistent with old healed TB; and
 persons who are immunocompromised by other medical conditions or
medication.
Ten millimeters or more of induration will be considered positive on all other
pre-placement PPDs.
Follow-up for Positive PPDs
A chest x-ray will be obtained for all individuals with a positive PPD.
In cases where the chest x-ray is negative or there is evidence of old healed
TB, the individual will be referred for possible INH prophylaxis (unless
previously treated) if:
documented convertor of any age;
SECTION 9 – HEALTH AND SAFETY POLICIES
less than 35 years of age; or
of any age with positive risk factors for TB (e.g., diabetes, immunosuppression,
HIV positive).
In cases where the chest x-ray is positive for suspected active TB or negative,
but with symptoms of TB, the individual will be counseled and referred for
immediate treatment. The individual will be placed on a medical hold (if not
yet working) or removed from work until a letter is received from the TB
clinic or the employee's health care provider stating that the individual is
not infectious and is cleared for work. The letter is to be placed in the
individual's employee health record. A confidential Morbidity Report is to
be completed and sent to the San Francisco Department of Public Health
(SFDPH).
Immunocompromised Health Care Workers
All health care workers (HCW) should know if they have a medical condition or
are receiving a medical treatment that may lead to severely impaired cellmediated immunity. HCWs who may be at risk for HIV infection should
know their HIV status, i.e., they should be encouraged to voluntarily seek
counseling
and
testing
for
HIV
antibody
status.
Severely
immunocompromised HCWs should avoid exposure to M. tuberculosis.
HCWs with severely impaired cell-mediated immunity (due to HIV infection
or other causes) who may be exposed to M. tuberculosis should consider a
change in job setting. Therefore, HCWs should be advised of options for
severely immunocompromised HCWs to voluntarily transfer to areas and
activities in which there is the lowest possible risk of exposure to M.
SECTION 9 – HEALTH AND SAFETY POLICIES
tuberculosis. This should be a personal decision for HCWs after being
informed of the risk to themselves and evaluating their own job
commitment and satisfaction.
Immunocompromised HCWs should be tested for anergy at the time of their
PPD testing. If the HCW is anergic, the following is to be considered:

A chest x-ray to rule out active disease

Chemoprophylaxis if the individual is working in a high-risk area

Counseling regarding the risk of developing TB from a workplace
exposure and the increased risk of rapid progression from latent TB
infection to active disease

Confidentiality of the HCW's immune status

If the HCW requests voluntary job reassignment, confidentiality of the
medical condition

Referral to a private health care provider for follow-up

PPD and anergy testing every six months
Periodic Tuberculosis Screening
The guidelines for periodic screening are that:
Periodic screening will be performed every six months for employees in high-risk
departments and annually for all other employees. This screening will be done
on a departmental basis. Individuals who have had a post-exposure PPD
placed in the last three months will notify Occupational Health.
SECTION 9 – HEALTH AND SAFETY POLICIES
 Employees with a prior negative PPD will receive a PPD and complete a TB
symptom review questionnaire. Employees with a prior documented positive
PPD will complete a TB symptom review questionnaire. Employees will be
instructed to report to Occupational Health if symptoms of TB occur and
referred for evaluation and treatment if indicated.
 Written notification of the PPD result and its interpretation will be provided to
each employee tested. Notification will include the following: “HIV infection
and other medical conditions may cause a TB skin test to be negative even
when TB infection is present.”
PPD Conversion
Conversion from a negative to positive PPD will be defined as an increase in
tuberculin reaction of greater than 6 millimeters (from less than 10
millimeters to greater than 10 millimeters within 24 months), or 5
millimeters induration or greater (regardless of the change since prior
testing) in those employees who:
 are known to be HIV positive or who have risk factors for HIV with unknown
HIV status;
 are immunocompromised due to other medical conditions, including long-term
use of corticosteroids or other immunosuppressive medication;
 have had close contact with cases of infectious TB; or
 persons who have had chest x-rays consistent with old healed TB
Follow-up of PPD Conversion
SECTION 9 – HEALTH AND SAFETY POLICIES
All employees who have a documented PPD conversion will receive a chest xray and medical review.
If the chest x-ray is negative, the employee will be counseled on the need for
prophylactic treatment with INH and then referred for evaluation. When
appropriate, forms will be filed with the workers' compensation insurance
carrier. A Confidential Morbidity Report will be completed and sent to the
SFDPH. If the employee is at high risk for HIV infection and is of unknown
HIV status, the employee will be referred for confidential HIV counseling
and testing.
If the chest x-ray is positive for suspected active TB or the employee has a
negative chest x-ray with symptoms of TB, the employee shall be
immediately removed from work and referred for evaluation and treatment.
When appropriate, forms shall be filed with the workers' compensation
insurance carrier. The employee shall remain off work until documentation
from the employee's treating health care provider is received stating that
the employee is asymptomatic and has smear-negative sputum after at
least fourteen days of treatment. A confidential morbidity report shall be
completed and sent to the SFDPH.
Exposure Investigation
An exposure investigation will be initiated for employees who have close
contact without appropriate engineering and personal protection to either
patient or staff with AFB smear-positive mycobacterium TB. Clinic staff will
SECTION 9 – HEALTH AND SAFETY POLICIES
determine if exposure is likely to have occurred and contact the department
manager to provide a list of exposed employees to Employee Health for
appropriate follow-up.
Employees who have had a documented negative past PPD shall be notified
to report to Employee Health for follow-up testing. The employee will
receive a baseline PPD within a week following notification (if no PPD
within the previous two weeks) and twelve weeks following the exposure.
Exposed employees, including those with prior positive PPD, shall be
advised to report to Occupational Health if they develop symptoms
suggestive of TB. Please refer to section on criteria for assessing PPD
conversion for information on follow-up.
Data Surveillance
Data shall be entered and reviewed in software database package
management for TB surveillance. The database will include, but is not
limited to, the following:
 demographic information
 occupation (job classification, department)
 past medical history
 PPD administration and results
 frequency of PPD screening (three, six, or twelve months)
 PPD conversion
 whether work-related
 chemoprophylaxis
SECTION 9 – HEALTH AND SAFETY POLICIES
 treatment referral
Data will be maintained in a confidential manner. The hard copy will be kept in
locked
employee health medical records. The database will be password protected.
Periodic reports of conversion rates will be generated at a minimum by job
location and occupational group not assigned to a specific job location.
The report will be made available to department managers and the Health
& Safety Policy Committee.
Reporting and Record Keeping
Public Health Notification
Cases of active TB shall be reported to the San Francisco Department of
Public Health (SFDPH) by the laboratory in accordance with applicable
reporting requirements. PPD conversions will be reported by Occupational
Health Services.
The treating physician will notify SFDPH of drugs
prescribed and the date they are first taken.
Employee TB Surveillance Data
TB skin tests, including the name or other identifier of the person tested, the date of the tests,
the result of the test in millimeters of induration, and the interpretation of the result, will be
recorded and maintained in writing by Campus Risk Management.
TB skin test conversions will be recorded on the log of occupational injuries and illnesses
(Cal/OSHA 200 Log) by Occupational Health Services.
Exposure Incidents
Exposure incidents, including the name or other identifier of the exposed employee, the date
and location of the incident, a description of the incident, follow-up evaluation and treatment,
and steps to be taken to prevent such incidents in the future will be recorded and maintained
in writing by the School of Dentistry Health & Safety Policy Committee.
Training
Documentation of TB and respiratory protection training will be maintained by EH&S for at least
three years and will include the employee's name or other identifier, training dates, and
training provider.
Program Review
The School of Dentistry TB Exposure Control Plan will be reviewed and revised, as needed, on
an annual basis by the Health & Safety Policy Committee, in consultation with UCSF
Occupational Health and other appropriate committees.
.
V. IONIZING RADIATION POLICY
The primary goal of this policy statement is to establish a consistent standard concerning the
diagnostic use of ionizing radiation within the School of Dentistry in order to minimize as
much as possible any potential risk of adverse biological effects to patients, students, faculty,
and staff within the School of Dentistry.
A standing Radiation Safety Committee, a subcommittee of the Dean’s Advisory Committee on
Health and Safety, is responsible for making recommendations to the Dean regarding the
establishment, implementation, monitoring, and enforcement of school-wide guidelines
aimed at ensuring the safe and effective use of ionizing radiation for clinical, teaching, and
research purposes throughout the School of Dentistry.
The Radiation Safety Committee of the School of Dentistry shall review and update the policy
annually or as required and recommend changes as appropriate. The Committee shall be
comprised of members from the School’s departments. The chair and members shall be
appointed by the Dean of the School of Dentistry. The chair who shall act as the Radiation
Safety Officer for the School of Dentistry (DSRSO), shall be a faculty member of Oral
Radiology in the Department of Orofacial Sciences with either appropriate experience or
advanced training in this field.
Ex officio members of the Committee shall include a
representative from the Clinic Management Committee of the School of Dentistry and a
representative from the Campus Radiation Safety Committee who can provide necessary
specialty expertise and ensure that policies are compatible with the goals and objectives of
the users of ionizing radiation. The chair of the Radiation Safety Committee of the School of
Dentistry, or the chair’s designate, shall also serve on the Campus Radiation Safety
Committee.
This policy complies with the Federal Radiation Control for Health and Safety Act of 1969 and
the Consumer-Patient Radiation Health and Safety Act of 1981, and it describes regulations
that equal or exceed those mandated by the state of California, the city and county of San
Francisco, and the UCSF Radiation Safety Committee.
.
All radiographic equipment and facilities meet the regulations and recommendations of the
Radiation Control for Health and Safety Act of 1969, NCRP Report #35, #105, and #107,
HHS Publication FDA 84-8225, and the ADA Council on Dental Materials, Instruments and
Equipment.
POLICY STATEMENT DRAFT
CRITERIA FOR EXPOSURE
Dental exposure of the patient to x-radiation shall be kept at a minimum level consistent with the
clinical requirements of each individual patient. The areas to be exposed in each case shall be left to
the professional judgment of a supervising dentist.
Current FDA/ADA guidelines for prescribing
radiographs shall be used as an aid in determining the appropriate radiographic survey.
All requests for radiographs must be authorized by a licensed dentist. A record of the radiation
history of every patient of the Dental School shall be kept as part of the patient record.
EXPOSURE PROCEDURES
During exposure of patients for diagnostic dental radiographs, operators must follow UCSF
Infection Control Procedures, prescribed exposure techniques and appropriate radiation
safety protection of patients and operators.
PROCESSING AND MOUNTING
Digital imaging is the primary method utilized here. If film must be used in certain situations, it
shall be adequately processed to achieve archival quality and labeled for proper
identification. A written interpretation of all films shall be included in the appropriate area of
the patient’s dental record and counter-signed by a dentist.
QUALITY ASSURANCE PROGRAM
.
This program is designed to produce radiographs of consistently high quality with minimal
patient exposure.
All operators who expose radiographs must be technically competent.
Students must be supervised by faculty or staff during their training in clinical radiography.
X-ray machine performance, computer equipment,
and processing systems shall be
monitored regularly.
RADIATION MONITORING
Selected clinical areas shall be monitored with film badges for radiation exposure. Those who
regularly use x-ray equipment may also wear film badge monitors while at work. Refer to the
Campus Policy on Ionizing Radiation regarding pregnant personnel for fetal monitoring.
PHYSICAL FACILITIES AND EQUIPMENT
Records shall be maintained of all employees who are permitted to make radiographic
exposures and all x-ray generators owned by or used within the School of Dentistry and its
affiliated facilities.
Criteria for Exposure
General Guidelines
Deliberate exposure of an individual to dental radiographic procedures for training or
demonstration purposes shall not be permitted unless there is a documented
diagnostic need for the exposure by a member of the dental faculty or supervising
dentist at UCSF.
Administrative radiographs or radiographs made solely for third parties such as
insurance claims or legal proceedings shall not be made. Duplicates of diagnostic
radiographs may be used for administrative purposes.
Dental research projects requiring exposure of human subjects to ionizing radiation must
be approved by the UCSF Committee on Human Research.A copy of the
proposal shall be available to the Dental School Radiation Safety Officer
(DSRSO) and the Radiation Safety Committee of the School of Dentistry.
.
New Patients to the Dental Clinic
Newly registered clinical teaching patients shall have an adequate radiographic
examination consistent with history and clinical examination prior to completion of
Baseline Evaluation and treatment in the School’s clinics.
A complete radiographic survey shall demonstrate each root apex and periapical
bone and each crown with minimal overlapping.
If recent radiographs are available from a private dentist or another institution, they
shall be requested and reviewed by the supervising dentist. Only those additional
views needed to complete a suitable diagnostic survey shall be taken.
Edentulous patients shall receive a panoramic radiograph with supplemental
periapical films if needed or a combination of occlusal and periapical radiographs
as deemed appropriate by the attending dentist.
Child patients shall receive radiographic examinations consistent with their
developmental age and clinical indications.
Endodontic Patients
The radiation exposure of endodontic patients for pre-operative, working, and postoperative radiographs shall be kept at a minimum level consistent with clinical
requirements. The limits of exposure in each case shall be determined by the
professional judgment of the supervising dentist.
If multi-angle projections are required, documentation of their need shall be made
in the treatment record by the supervising dentist prior to radiographic exposure
.
Emergency Patients
.
Only those radiographs needed to provide information relevant to the diagnosis and
management of the immediate emergency problems shall be requested.
Periodic Radiographic Exams
The frequency and extent of radiographic examinations of dental school patients (full-mouth
survey, panoramic, bitewing) shall be based on the needs of the patient as determined by
the supervising faculty or staff dentist.
Board Examination Patients
Request for radiographs on all Board Examination patients shall be authorized by
a licensed dentist.
Radiographs of Board Examination patients shall be made under the supervision of
the Oral Radiology staff or faculty.
The need for radiographs shall be established by clinical indication and
professional judgement and contribute to the proper diagnosis and treatment of the
patient.
The Radiation Safety Policy of the UCSF School of Dentistry shall be observed for
all board examination patients.
Radiation History Record
A record of the radiation history of every patient of the dental school shall be kept as part of
the patient record and monitored as part of the chart audit process.
The request for radiographs shall be authorized by a faculty or staff dentist.
Exposures shall be recorded in the patient chart.
Interpretation of radiographic findings shall be documented in the patient chart (see
Appendix E for the worksheet example)
Exposure Procedures
UCSF Infection Control Procedures shall be used during all exposures
(See Appendix F, Appendix G, Appendix H, Appendix I, and Appendix J for current
protocol).
.
Prescribed exposure techniques shall be followed; appropriate exposure procedures are
mounted on the wall of each x-ray cubicle.
Leaded aprons shall be used on all oral radiology patients at UCSF as an additional
precaution to prevent unnecessary scatter radiation exposure to the body of the
patient. A thyroid collar shall be used if it does not interfere with the radiographic
study.
The operator must stand behind the barrier provided for each x-ray cubicle in the
UCSF dental facilities and directly observe the patient during each exposure.
The exposure control switch shall be immobilized and require continuous pressure
throughout the exposure.
Digital retention of intraoral films by operators or patients shall be avoided. If assistance
is required for the patient, an adult member of the patient’s family or non radiation worker
may help while wearing a leaded apron and staying out of the primary beam.
The tube housing and cone must be stable and the patient’s hand must not be in the field
of the beam or used to stabilize the cone. If equipment is not stable, the operator shall
not proceed but shall report the problem to the radiology clinic supervisor. The
supervisor shall make adjustments as appropriate or assign another operatory.
Only shielded open-end cones or position-indicating devices (PIDs) shall be used in order
to minimize scatter radiation.
Rectangular collimation that decreases the beam to the size of the film must be
used whenever anatomically possible in order to minimize scatter radiation.
When a cylindrically collimated x-ray machine is being used, the circular beam
striking the face shall not be more than 2.75 inches in diameter.
Either a digital receptor or the fastest film available which provides sufficient diagnostic
information under existing viewing conditions shall be used.
.
Extraoral radiographs shall be restricted to the area in question and made with the beam
collimated to the size of the receptor or smaller.
For extraoral surveys, the fastest receptor-screen combination appropriate for diagnostic
yield shall be used.
Each dental x-ray machine shall contain filtration not less than 2.5 mm of aluminum (Al)
equivalent. Additional filtration of the x-ray beam shall be used when possible. Total
filtration as equivalent mm of Al shall be noted adjacent to the control panel.
Periodic radiation protection surveys and inspections shall be made by the DSRSO. All
recommendations by the DSRSO concerning collimation, filtration (HVL), beam
alignment, roentgen output, radiation leakage, etc., shall be implemented immediately.
Processing, Mounting, Storage, and Viewing
All unexposed film is stored in the x-ray clinic, and film is used according to age
sequence. Outdated film shall not be used for patients. Film shall be dispensed by
faculty or staff only for procedures prescribed in writing. Dispensed but unexposed film
shall be returned to appropriately marked containers for non-clinical use.
UCSF Infection Control Procedures shall be used during processing of films (See
Appendices D and E for current protocol).
All films shall be properly developed, fixed, washed, and dried.
Instructions for processing x-ray film are displayed in each darkroom and adjacent to
each daylight-loading processing system.
Complete development techniques (time temperature processing) shall be
employed when using normal “hand” processing or automatic film processing
equipment. If the films are too dark in density, the exposure technique and / or
processing procedure for that particular machine shall be evaluated and corrected
.
immediately by the faculty dentist or supervising dental x-ray technician on duty in
the x-ray clinic before that unit is used again.
When dry, one film from each packet of processed films shall be placed in appropriately
labeled mounts. The label must have the patient’s name and the date of the exposure.
Other identifying information, i.e., chart number, date of birth, and name of operator, shall
be added if available.
Duplicate Films
For double intraoral film packs, the second processed film shall be placed in a
labeled duplicate envelope.
Whenever a double panoramic film is used, both films shall be appropriately
labeled. One panoramic film will be placed in the chart and the second copy stored
in the duplicate filing area.
Duplicates and copies of radiographs shall be stored in a filing area separate from
the patient record.
The filing area must be sufficiently organized and maintained for ease of access to
the duplicates for a given patient. These duplicate radiographs are part of the
patient’s record and shall be treated as confidential material.
Immediate access to duplicate radiographs for a given patient must be possible for
seven years. After seven years, duplicate radiographs may be stored away from
the main site with continued timely access.
Digital images shall be saved in their original state by the imaging software and can only be
deleted by authorized administrative personnel.
Images shall be interpreted under adequate viewing conditions.
.
Quality Assurance Program
The Radiation Safety Committee shall review the quality assurance program annually or as
necessary to monitor the adequacy of radiographic personnel training and equipment.
Technical Competence
All employees who expose radiographs shall hold a current Radiation Safety
Certificate from a program approved by the California State Board of Dental
Examiners. Staff members who perform intraoral radiography shall be required to
demonstrate technical competence on a mannequin, using rectangular collimation
for periapical exposures.
Students shall make clinical radiographs only after they have demonstrated
technical competence on a mannequin and/or successfully completed the Oral
Radiology Rotation of Patient Centered Care 117. (Appendix K)
There shall be general supervision of all students during radiographic
procedures.
Students who must retake three or more exposures shall be directly supervised
and instructed by the faculty and/or staff.
All operators must use sensor/film holders and alignment devices that employ
rectangular collimation decreasing the beam to the size of the film whenever
anatomically possible.
All radiographs shall be reviewed for errors by a department faculty or staff member
immediately after they are exposed. If possible, any indicated retakes shall be made on
the same visit.
A retake log shall be maintained for all operators for review by course directors and
the DSRSO.
Evaluation of X-ray Machine Performance
.
The quality control staff member (QCSM) and a backup shall be identified by the
director of each clinical facility. Each QCSM shall attend a training session initially
and in-service training yearly.
The QCSM in each x-ray clinic shall view images taken during the day,
“trouble shooting” for exposure errors. If the error is due to x-ray machine
performance instead of human error, it will be corrected immediately or the
machine will be not be used until the unit has been calibrated by dental xray maintenance personnel.
The QCSM shall assure that UCSF x-ray procedures are in compliance with
the California State Department of Health and requirements of the Bureau
of Radiological Health, FDA.
A log of discrepancies and repairs shall be kept for each unit.
Yearly, in concert with the Environmental Health and Safety (EH&S), all dental xray machines shall be calibrated and safety procedures evaluated. The following
tests shall be included in the evaluation of equipment performance: beam
diameter, spacer size, filtration including HVL, exposure, and tube housing leakage.
Evaluation of operational safety procedures shall include reviewing room design,
operator position, patient shielding, and film storage (Appendix L).
Records for all units shall be kept by EH&S and the DSRSO.
Any readings out of tolerance shall mandate reset, repair, or replacement of
parts or units followed by recalibration and report with EH&S.
Identification of Processing Problems
The DSRSO shall establish a performance standard film wedge for each location.
Before any patient films are processed, the QCSM shall perform a daily check of
the processing systems and shall match the test film to the standard. If there is a
discrepancy, the QCSM shall solve the temperature or replenishment problem and
repeat the test . If the discrepancy remains, the Processor will be taken out of
service for repair.
Periodic QC films shall be identified, mounted, and kept in a log book as prescribed
during the yearly in-service training.
.
Radiation Monitoring
Selected areas shall be monitored as deemed appropriate by the Radiation Safety Committee.
Quarterly reports shall be kept on file by EH&S and the DSRSO.
The DSRSO shall investigate the cause when any area monitor has a quarterly reading in
excess of 5 mSv (milliSievert) and shall institute personnel monitoring if appropriate.
Individual staff may request monitoring with film badges. Fetal monitoring for pregnant
personnel is available by arrangement with EH&S. Records for these individuals will be
maintained by EH&S and the DSRSO.
.
Physical Facilities and equipment
The DSRSO shall maintain an inventory of the location and operational status of all x-ray
generators owned by or used within the School of Dentistry and its affiliated facilities.
The DSRSO shall maintain a record of all employees who are permitted to make
radiographic exposures.
Installation or relocation of all x-ray generators shall be approved by the campus RSO
who shall further inform the DSRSO.
Since portable x-ray machines present radiation protection difficulties, they shall have
appropriate barriers. Portable barriers, vinyl sheet lead and clearing individuals from
adjacent areas shall be used where indicated. All portions of this policy pertain to the use
of portable units.
.
APPENDIX E
.
APPENDIX F
INFECTION CONTROL PROTOCOLS FOR RADIOGRAPHIC PROCEDURES
Protocol for Full Mouth Radiographic Series or Single Exposure Using Digital Imaging
Prepare the room for use:
1. Cover the patient chair and X-Ray tube with plastic bags provided. Tie the plastic bag
on the X-ray tube over the yolk.
2. Cover the control box with plastic wrap from the roll provided and attach it to the wall
with a small piece of tape.
3. Cover the computer monitor and keyboard with plastic bags.
4. Place a plastic bag on top of the utility shelf.
5. Obtain a sterilized set of instruments, a few cotton rolls and Edge-eez tabs and place
them on the utility shelf.
Seat the Patient
1. Seat the patient and adjust the head rest for the patient. Place the lead apron and
thyroid shield on the patient.
2. Put on latex gloves, assemble the instruments and place a barrier on the sensor, resting
them on the covered utility shelf.
3. Begin the procedure by setting the first indicated exposure.
4. Place the covered sensor in the patient’s mouth, adjust the tube and make the exposure.
5. Remove the sensor from the patient’s mouth, wipe it with a paper towel to remove
excess saliva, and check the plastic barrier for damage. Replace the barrier if
necessary. If the image is not acceptable, ask the supervising instructor or technician
for assistance before continuing. Repeat the process until the FMX series is completed.
6. After the FMX is confirmed to be diagnostic by the supervisor, dismiss the patient.
Complete all necessary documentation in the patient’s electronic chart and obtain final
approval by the supervisor.
.
APPENDIX G
INFECTION CONTROL PROTOCOL FOR RADIOGRAPHIC PROCEDURES USING FILM
These protocols are to be used for all patients.
Prior to seating the patient
1. Work with supervising faculty or technician to access patient record and confirm radiographic
request.
2. Prepare imaging software.
3. Pick up supplies, including:
A pair of latex gloves
A pair of overgloves
Film in a plastic bag
Sterile instruments
4. Prepare the room for use.
Cover the patient chair and x-ray tube with plastic dry-cleaning bags.
Tie the plastic bag on the x-ray tube.
Cover work tables with plastic covers.
Cover the control box with plastic wrap from the roll provided.
5. Call patient and proceed to the x-ray room.
.
Seat the patient
1. Seat the patient and place lead apron and thyroid shield on the patient.
2. Put on latex gloves, prepare instruments and film on the work table and begin procedure by setting
the first indicated exposure.
3. Place the film in the patient’s mouth, adjust the tube, and expose the film.
4. Remove the film from the patient’s mouth, wipe with a paper towel to remove excess saliva, drop it
into the plastic bag and place a new film in the holder.
5. After all radiographic exposures are completed, ask your patient to wait in the appropriate area of
the clinic.
6. Put on overgloves and bring exposed film (in the plastic bag) and a disposable cup in the darkroom.
.
APPENDIX H
INFECTION CONTROL PROTOCOL FOR PROCESSING RADIOGRAPHS
IN AUTOMATIC PROCESSORS WITH DAYLIGHT LOADERS
1.
Proceed to the automatic processor with:
Exposed film in a plastic bag
Disposable cup
Overgloves covering your latex gloves
2. With overgloves over latex gloves, place a disposable cup and the exposed film(s) within a bag or
cup inside the daylight loader.
3. After placing both hands inside the daylight loader through the elastic cuffs, take off the overgloves.
4. The film(s) from each packet is/are carefully dropped from the packet into the clean cup until all
packets have been “unloaded.”
5. The lead foil of each packet should be placed into a container labeled for that purpose.
6. After unloading all films, wrap up remnants of the packets in the plastic bag or cup. Remove latex
gloves, wrapping them around the debris.
7. Place each film (or separated pairs of film) into one of the slots of the automatic processor. Allow 10
seconds before sending the next film through the same slot (by counting “1-1000, etc.”) to prevent
jamming the roller.
8. After all films have been completely fed into the machine, remove your hands from the cuffs of the
daylight loader along with the wrapped debris to be discarded in the garbage can.
.
APPENDIX I
INFECTION CONTROL PROTOCOL
FOR PROCESSING RADIOGRAPHS IN THE DARKROOM
Enter the Darkroom with: Exposed film in a plastic bag
Disposable cup
Overgloves covering your latex gloves
1. Place the cup and the plastic bag with exposed films on top of the automatic processor to be used.
2. Dispose of the overgloves. Retain the latex gloves while opening the film packets.
3. The film(s) from each packet is/are carefully dropped from the packet into the cup until all packets
have been “unloaded”.
4. The lead foil of each packet should be placed into a container labeled for that purpose.
5. The wrappings from the packets are placed in the garbage container during the unloading
procedure.
6. After unloading all films, dispose of the plastic bag and latex gloves in the garbage container.
7. Place each film (or separated pairs of film) into one of the slots on the automatic processor. Allow
10 seconds before sending the next film through the same slot (by counting “1-1000, etc.”) to
prevent jamming the roller.
8. After all films have been placed in the processor, wait in the darkroom until processing is completed
(usually 5 - 6 minutes). Keep the duplicate films from each slot separated to facilitate the mounting
procedure. Then bring the films to the designated film mounting/viewing area.
.
APPENDIX J
CLEANING OF RADIOGRAPHY OPERATORY
After the radiographs have been reviewed, chart documentation completed and the patient
dismissed, the radiographic operatory is cleaned and disinfected. A new sterilization
pouch/bag and gloves will be needed. Disinfectant solution is provided in the operatories.
1. While wearing gloves, remove the plastic bags from the patient chair, X-ray tube, computer monitor,
keyboard and control panel.
2. Rinse the sensor holders with warm water and dry with a clean paper towel. Place the holders in a
new autoclave bag.
3. Remove the sensor barrier and place the sensor in the holder mounted on the wall. Throw out the
plastic cover on the utility shelf along with any disposable items that were used.
4. With clean gloves use a paper towel moistened with disinfectant to wipe off the sensor and all
surfaces that were touched during the procedure (such as yoke, tubehead, control panel, lead
apron). Start with the least contaminated surfaces. Throw out these gloves and towel(s).
5. Return the sensor holders in the new autoclave bag to the appropriate location for sterilization.
Wash your hands thoroughly.
6. Return the lead apron/thyroid shield to the wall hanger. DO NOT FOLD! Folding the lead apron
will result in breaks in the lead and decreased protective function.
.
APPENDIX K
COMPETENCY TESTS FOR INTRAORAL RADIOGRAPHY
In one hour, the operator must produce one-half of a full mouth survey including bitewings on a
mannequin with no more than three retakes required. Rectangular collimation must be used for
periapical radiography.
.
APPENDIX L
RADIOGRAPHIC EQUIPMENT SURVEY REPORT DENTAL UNIT
Unit ID
Control
Maker
Max kvp:
__________________________
Tube
_____________________________
Special Features
ITEM
Dept.
Location
______________________
Model
________________________
Max mA
______________________
Cone
length:__________________
STATUS
1 Tube housing
___________
2 Radiation leakage
___________
3 Beam diameter
___________
4 Target to skin distance
___________
5 Exposure indication
___________
6 Control panel indicators
___________
7 Timer accuracy/linearity
___________
8 Exposure switch type/location
___________
9 Patient shields
___________
10 Cephalomatic beam alignment
___________
11 Filtration
___________
12 kVp
___________
13 Controlled area survey
___________
14 Uncontrolled area survey
___________
S=Satisfactory, U=Unsatisfactory, NA=Not applicable, NI= Not Inspected
COMMENTS:
.
Surveyor:
Date:
RADIOGRAPHIC MEASUREMENTS WORKSHEET
DENTAL UNIT
Date:_______________
Unit I. D.:
________________
Radiation leakage:
kVp: ______________
mR/hour at one meter.
mAs:
Timer-Exposure
Measurement
Time
mA
mAs
mR
set measured
measured
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________
Collimation:
beam diameter:
________________________________________________________
Uncontrolled area survey:
________________________________________________
kVP measurement
set
___________________________________________________________
.
measured
___________________________________________________________
error
___________________________________________________________
Filtration
mmAl:
exposure
mAs:
3.5
HVL:
0
Focal Spot Size
_______________
1.5
2.5
nominal: _________________
.
kVp:
4.5
measured:
SECTION 9 – HEALTH AND SAFETY
Scatter Radiation Survey
kVp _________
mA __________
time __________
Location
reading
note
Revised: Feb-11
SECTION 9 – HEALTH AND SAFETY
VI. Healthcare Personnel with Bloodborne Infections
A. Healthcare personnel who are fit for duty as affirmed by their treating
physician may continue regular patient care activities including the
performance of invasive procedures regardless of their bloodbome infection
status, providing that UCSF infection control policies and procedures are
followed. Evaluation of healthcare providers whose fitness tor duty is
questioned will proceed according to existing mechanisms at UCSF.
B. The Dean's Advisory Committee on Health and Safety provides confidential
consultation to healthcare workers who are considering modification or
discontinuation of their professional activities as a consequence of bloodbome
infection.
C. When there is compelling evidence that a healthcare provider has been
involved in the transmission of bloodborne pathogens to a patient. clinical
privileges and/or patient care responsibilities will be reviewed for appropriate
action by the responsible department and a designee from the UCSF Infection
Control Committee.
D. Management of Patient Exposures
1. Patients will be informed that healthcare personnel are not required
to have screening for bloodborne infections.
E. Patients who sustain an exposure as defined in Premise B will be
informed that such an exposure has occurred. Post-exposure
be handled by the same mechanism as healthcare
follow-up will
exposure - 353-7842
(STIC)
Revised: Feb-11
SECTION 9 – HEALTH AND SAFETY
F. Following a patient exposure as defined in Premise B. it is an ethical and
professional responsibility of the source healthcare worker to undergo testing
for human immunodeficiency virus and hepatitis. The test results will be
confidential and handled pursuant to appropriate procedures.
Revised: Feb-11
SECTION 9 – HEALTH AND SAFETY
VII.
OSHA NEEDLE SAFETY REQUIREMENTS
Revised: Feb-11
SECTION 9 – HEALTH AND SAFETY
Revised: Feb-11
SECTION 10 – INFECTION CONTROL PROTOCOL
I.
INTRODUCTION TO INFECTION CONTROL CONCEPTS
“You must see with your mind’s eye the living germs which attempt to infect
the wound from the air; see them as clearly as you perceive flies with your
body’s eye”
Lord Joseph Lister
A. To achieve a high standard of infection control, it is essential to
develop an awareness of the current level of cleanliness or
contamination of your gloved hands and of any object you may touch,
and to carry that awareness with you at all times.
B. In particular, any object may be classified as contaminated (for
example, with blood or saliva), sterile, or simply “clean” (neither
contaminated nor sterile). A “clean” object may carry the types and
low amounts of micro-organisms normally present in a non-clinical
environment.
C. If an object in a higher category of cleanliness or sterility comes into
contact with an object in a lower category, its status will be converted
to that of the lower category. For example, if a person wearing a
contaminated glove reaches into the mask box to remove one, then
that mask and all the other masks in the container are now
contaminated.
D. The infection control guidelines are intended to foster an awareness of
these concepts and methods when performing required patient care
procedures. For your safety and the safety of others, the general
principles of cleanliness in the workplace, the use of protective attire,
the separation of uncontaminated and contaminated items and work
areas, and a constant consideration of the potential for crosscontamination should be observed.
II.
CLINIC POLICY ON THE USE OF HYPOALLERGENIC GLOVES
Revised: Apr-11
SECTION 10 – INFECTION CONTROL PROTOCOL
A. The (hypoallergenic) gloves provided by the clinic dispensaries are for
individuals who have a legitimate allergy to latex gloves.
B. If you wish to have hypoallergenic gloves issued to you, you must obtain
a medical provider’s prescription for the use of these gloves. The
documentation must state that you are allergic to latex gloves. Please
submit your medical provider’s prescription to the Student Store
personnel (D-1046) as soon as possible. The facilities manager, will
maintain a master list of individuals authorized to receive hypoallergenic
gloves and will forward this information to the clinic dispensary assistants.
III.
INFECTION CONTROL PROTOCOLS FOR CLINICAL PROCEDURES
A. Infection control protocols apply to all patients
B. Clinical Safety Protocol
1. Constantly consider the potential for cross-contamination
2. Take the time to plan your procedure and set up your operatory
accordingly. It will save you time in the end and preserve the
integrity of your operatory.
3. Secure long hair and loose fitting clothing as appropriate.
4. Always create a proper barrier by wearing:
a.
Gloves (always wash hands before and after gloving)
b.
A mask
c.
Protective eyewear with side shields or face shield
d.
A gown
5. Always wash your hands with soap before gloving and always
place gloves on as the last step before entering the mouth (after
glasses and mask are in place). (link to UCSF Hospital
Epidemiology and Infection Control 1.2 Hand Hygiene Policy)
http://infectioncontrol.ucsfmedicalcenter.org/ICMANUAL2007/Secti
on1/Sec%201.2%20Hand%20Hygiene%20Policy.pdf
http://infectioncontrol.ucsfmedicalcenter.org/html/ICManual.html
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SECTION 10 – INFECTION CONTROL PROTOCOL
6. NEVER leave the operatory with just your exam gloves on. Have a
pair of plastic overgloves available in case there is a need to:
a.
LEAVE THE OPERATORY
b.
OBTAIN AN ADDITIONAL PIECE OF EQUIPMENT
c.
GO TO THE DISPENSARY OR SUPPLY CART
d.
GO INTO AN UNCONTAMINATED AREA
7. “Clean and Disinfect” using one of these methods:
a.
SOAK IN DISINFECTANT FOR 10-30 MINUTES
b. SPRAY WITH DISINFECTANT AND A 10-MINUTE AIR
DRY
c. WRAP IN DISINFECTANT-SOAKED GAUZE FOR 10
MINUTES
8. If a piece of equipment (for example, a triturator) is obtained from
someone else on the clinic floor, be sure to clean and disinfect it
before use.
9. Be extremely careful with used injection needles. We recommend
recapping needles using a single-handed technique (e.g., scoop or
approved holding device). This facilitates safe disposal.
10. Any impression or intraoral record made during a planned
procedure must be cleaned and handled in the manner stipulated
in the Protocol for Restorative Procedures, both in the operatory
and in the laboratory. Refer to the protocol as necessary.
11. Likewise, any denture or appliance taken from a patient for a
laboratory procedure must be cleaned and handled in the manner
stipulated in the Protocol for Laboratory Procedures, both in the
operatory and in the laboratory. Refer to the protocol as necessary.
C. Protocol for Baseline Evaluation
1. These protocols are to be used for all patients
2. Before Seating the Patient:
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SECTION 10 – INFECTION CONTROL PROTOCOL
a.
Put on a clean gown
b. Put on a pair of plastic overgloves when arriving at the
cubicle.
c. Prepare the cubicle for use by removing debris from the
floor and counter tops and disinfecting the following
surfaces by spraying with the provided disinfectant
solution and wiping with a 2x2 gauze pad or paper towel
saturated with disinfectant:
i.
Handles, receptacles, brackets and valves of saliva
ejector, high speed evacuator
ii.
Switches and knobs on cart
iii.
Cart and counter surfaces, including radiograph
viewbox buttons
iv.
Patient and operator chairs
v.
Air-water syringe handle
vi.
Sinks and faucet handles
3. Flush air-water syringe and handpiece hoses for 30 seconds in the
sink between patients. Flush lines for a full two minutes prior to
the first patient of the day. Remove and dispose of overgloves.
4. Wash hands. Turn faucet handles on and off with elbows when
possible to avoid cross-contamination.
5. Proceed to supply cart and dispensary to pick up disposable
supplies and equipment borrowed from the dispensary. These
should include a sphygmomanometer and a stethoscope (when
appropriate), gown and mask.
6. Set up protective covers and supplies and arrange instruments:
a.
Put chart, pencils, pens, mask, exam gloves and plastic
overgloves on counter
b.
Place paper liner on instrument cart
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SECTION 10 – INFECTION CONTROL PROTOCOL
c.
Place examination instrument tray on cart
d.
Arrange exam set and 2x2 gauze pads, tongue blade,
cotton rolls, floss and articulating paper
e.
Place protective covers on counter tops where
instrument trays will be placed
f.
Place protective cover on headrest and light handles
g.
Attach debris bag to instrument cart with tape
h.
Place medicament/supply tray on counter top
i. Place disposable saliva ejector and high/low volume tips.
j. Place a disposable tip on the air/water syringe.
7. IT IS EXTREMELY IMPORTANT THAT YOU TAKE THE TIME TO
PLAN YOUR PROCEDURE AND SET UP PROPERLY. IT WILL
SAVE YOU TIME IN THE END AND PRESERVE THE
INTEGRITY OF YOUR OPERATORY.
8. Proceed to reception area and call patient. Seat patient, adjust the
chair and place patient napkin (use tape or disposable bib "chain").
9. Review medical history verbally with the patient, take vital signs,
and request any additional medical consultation; request a start
check from the instructor
10. Wash hands for 1 minute with soap.(see link above) Turn faucet
handles on and off with elbows when possible. Put on mask and
protective eyewear. Put on exam gloves in front of patient.
11. Attach handpiece(s) if needed for this session.
12. Evaluate the patient extraorally before beginning the intraoral
evaluation
13. STUDENTS ARE ENCOURAGED TO ASSIST ONE ANOTHER
BY CHARTING FOR THE BASELINE EVALUATION. However, if
you are performing the examination alone, ALL chart entries are to
be made in the following manner:
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SECTION 10 – INFECTION CONTROL PROTOCOL
a.
Turn from patient and put on plastic overgloves
b.
Pick up pen/pencil and record chart entry, (if making entires
on a paper record)
c.
Remove plastic overgloves
d.
Return to patient
14. The protocol detailed above will be repeated as often as necessary
while recording all elements of the baseline procedure including:
a.
Extraoral Examination
b.
Intraoral Examination
c.
T.M.D./Occlusal Examination
d.
Radiographic Interpretation
e.
Baseline Record
f. Periodontal Screening Examination
g.
Preventive Dentistry Evaluation
h.
Case History and Report
i. Comprehensive Treatment Plan
j. Procedure Plan
15. If there is a need for a consultation that requires you and the
patient to leave the operatory, remember to put on plastic
overgloves before leaving the cubicle. As often as is possible, have
an instructor come to the cubicle and perform the consultation
there.
16. IT IS EXTREMELY IMPORTANT THAT YOU ALWAYS
OVERGLOVE WHEN YOU:
a.
LEAVE THE OPERATORY FOR AN INSTRUCTOR
CHECK
b.
OBTAIN AN ADDITIONAL PIECE OF EQUIPMENT
c.
GO TO THE DISPENSARY OR SUPPLY CART
d.
GO INTO AN UNCONTAMINATED AREA
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SECTION 10 – INFECTION CONTROL PROTOCOL
17. ANY IMPRESSION OR INTRAORAL RECORD MADE DURING
THE PROCEDURE MUST BE CLEANED AND HANDLED IN THE
MANNER STIPULATED IN THE PROTOCOL FOR
RESTORATIVE PROCEDURES BOTH IN THE OPERATORY
AND IN THE LABORATORY.
18. Put on a pair of overgloves. Finish required charting and make
your treatment record entry. Review the baseline findings with an
instructor; request final signatures.
19. After the procedures for that session are completed, remove the
patient napkin and saliva and High Volume Evacuation ejector and
place them in the debris bag attached to the instrument cart.
20. Remove overgloves and exam gloves and place in the debris bag.
Remove mask and protective eyewear and dispose of mask in
debris bag.
21. Explain to the patient at the chair what the fees are and what is
planned for the next visit.
22. Dismiss the patient by walking patient to reception area and
delivering Careslip to the clinic or appointment assistant.
D. After Dismissing the Patient
1. Wipe instruments carefully during the course of treatment to eliminate
or minimize scrubbing. If there is a need to scrub instruments, place
instruments in the sink, put on heavy duty blue gloves and scrub/rinse
as necessary to remove blood and debris. Place on a clean paper
towel. Put on a pair of plastic overgloves.
2. Flush air-water syringe and handpiece hoses for 30 seconds between
patients. Flush lines for a full two minutes prior to the first patient of
the day.
3. Remove all coverings from chair, light, cart and counter tops and
place them in debris bag.
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SECTION 10 – INFECTION CONTROL PROTOCOL
4. Repeat disinfectant spray and 2x2 saturated gauze or saturated paper
towel wipe down of the operator chair, instrument cart, counter tops
and sinks (spray, wipe, and spray technique). The patient chair should
be wiped with disinfectant, not sprayed.
5. Blot instruments dry and inspect to be sure they are free of debris.
Clean and disinfect any equipment borrowed from the dispensary by
spraying with disinfectant and wiping with 2x2 saturated gauze or
saturated paper towels. Return items to dispensary.
6. Place all handpieces which were actually used in the mouth into an
appropriate cassette.
7. Clean and disinfect materials that are not autoclavable by wiping with
disinfectant-saturated 2x2 gauze or saturated paper towels and
allowing to air dry for 10 minutes.
8. Place all instruments and equipment in an appropriate cassette for
sterilization.
9. Place each handpiece in a cassette that has your bar-coded label
attached
10. Remove plastic overgloves and place in debris bag. Remove debris
bag and tie or tape closed before disposal.
11. Place in the trash container.
12. Place all cassettes in your dispensary collection containers after each
patient for each clinic session (no later than 12:15 or 5:15 or 9:00 PM
for Thursday Night Clinic) for sterilization.
E. Protocol for Restorative Procedures
1. THESE PROTOCOLS ARE TO BE USED FOR ALL PATIENTS. IT IS
EXTREMELY IMPORTANT THAT YOU TAKE THE TIME TO PLAN
YOUR PROCEDURE AND SET UP PROPERLY. IT WILL SAVE YOU
TIME IN THE END AND PRESERVE THE INTEGRITY OF YOUR
OPERATORY
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SECTION 10 – INFECTION CONTROL PROTOCOL
2. Before Seating the Patient:
a. Put on a pair of plastic overgloves when arriving at the cubicle.
b. Prepare the cubicle for use in the manner described in the
previous section on Baseline Evaluation Protocol in Step Three.
c. Proceed to the supply cart and dispensary to pick up instrument
set-up, disposable supplies, gown, mask, and equipment
required for the procedure you are planning to perform. Flush
air/water syringe and handpiece hoses for 30 seconds in the
sink. Remove and dispose of overgloves
d. Wash hands. Turn faucets on and off with elbows when
possible to avoid cross-contamination
e. Set up protective covers and supplies in the manner described
in the Baseline Evaluation Clinic Protocol
f. Set up the instrument tray for the procedure you are planning to
perform. In addition, obtain all items that will be required for this
procedure and set them out in the appropriate zone
g. Cover instrument tray with patient napkin until patient is seated.
h. Arrange necessary patient treatment forms. Proceed to
reception area and call patient
3. Seat the Patient
a. Seat the patient, adjust the chair, and place patient napkin.
Review with the patient what is planned for this session and the
fees. Review medical history with the patient; request any
additional medical consultation; request a start check from the
instructor.
b. Request an anesthetic signature from an instructor if required.
Proceed to the dispensary for a disposable needle and an
anesthetic carpule.
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SECTION 10 – INFECTION CONTROL PROTOCOL
c. Wash hands for 1 minute with soap. Turn faucets on and off
with elbows when possible. Put on mask and protective
eyewear. Put on exam gloves in front of patient
d. Place a disposable tip on the air/water syringe. Attach sterilized
handpieces as needed for this session
e. Begin the planned procedure by administering the appropriate
anesthetic
f. Isolate the operative area by placing a rubber dam and obtain a
rubber dam instructor check
g. During the course of the planned procedure, obtain instructor
evaluation and signatures as required for that procedure
h. IT IS EXTREMELY IMPORTANT THAT YOU ALWAYS
OVERGLOVE WHEN YOU:
i. LEAVE THE OPERATORY FOR AN INSTRUCTOR
CHECK
ii. OBTAIN AN ADDITIONAL PIECE OF EQUIPMENT
iii. GO TO THE DISPENSARY OR SUPPLY CART
iv. GO INTO AN UNCONTAMINATED AREA
i.
IT IS EXTREMELY IMPORTANT THAT YOU CONSTANTLY
CONSIDER THE POTENTIAL OF CROSS-CONTAMINATION.
Certain items are not autoclavable, easily disinfected or
disposable; these items should remain uncontaminated. An
example would be items, such as medicament jars, that will be
returned to an uncontaminated storage area after the
procedure has been completed. Keeping these items
uncontaminated is accomplished by ALWAYS OVERGLOVING
when using these items and by keeping contaminated and
uncontaminated items SEPARATED on the counter tops.
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SECTION 10 – INFECTION CONTROL PROTOCOL
j.
All alginate, hydrocolloid, polyvinyl siloxane and polysulfide
impression material should be handled in the following manner
after removal from the mouth:
i. Rinse the impression by filling with water and dumping
the water out three times
ii. Spray liberally with the disinfectant solution presently in
use and place in a sealed baggie for at least 10 minutes
iii. Rinse the impression again by filling with water and
dumping the water out three times
iv. Alginate and hydrocolloid impressions should be gently
dried and the casts poured as soon as possible. They
should be placed back in the baggie until the stone is
set.
v. Polyvinyl siloxane and polysulfide impressions should be
gently dried and the casts poured according the
manufacturer’s directions
k. Put on a pair of overgloves. Finish required charting. Obtain a
final instructor evaluation and electronic signatures. When the
planned procedure is completed, remove the patient napkin
and saliva ejector and place them in the debris bag attached to
the instrument cart.
l.
Remove overgloves and exam gloves and place in debris bag.
Remove mask and protective eyewear and dispose of mask in
debris bag.
m. Dismiss the patient by walking patient to reception area
4. After Dismissing the Patient
a. Wipe instruments carefully during the course of treatment to
eliminate or minimize scrubbing. If there is a need to scrub
instruments, place instruments in the sink, put on a pair of
Revised: Apr-11
SECTION 10 – INFECTION CONTROL PROTOCOL
heavy duty utility gloves and scrub/rinse as necessary to
remove blood and debris. Place on a clean paper towel. Put on
a pair of plastic overgloves. Return instruments to the cassette
properly sequenced
b. Prepare and clean the cubicle for its next use in the manner
described in the Baseline Evaluation Clinic Protocol.
c. Clean and disinfect any equipment borrowed from the
dispensary by spraying with disinfectant and wiping with 2x2
saturated gauze or saturated paper towels. Return items to the
dispensary.
d. Place each handpiece which were used in the mouth into an
appropriate cassette. Place all instruments and equipment in an
appropriate instrument box for sterilization
e. Clean and disinfect materials that are not autoclavable by
wiping with disinfectant-saturated 2x2 gauze or saturated paper
towels and allowing to air dry for 10 minutes
f. Remove overgloves and place in debris bag. Remove debris
bag and tie or tape closed before disposal. Place in the proper
receptacle
g. Place all instrument boxes in your clinic collection containers
after each patient for each clinic session (no later than 12:15 or
5:15 or 9:00 PM for Thursday Night Clinic) for sterilization
F. Protocol for Clinical Materials and Equipment
1. THESE PROTOCOLS ARE TO BE USED FOR ALL PATIENTS.
IT IS EXTREMELY IMPORTANT THAT YOU TAKE THE TIME TO
PLAN OUR PROCEDURE AND SET UP PROPERLY. IT WILL
SAVE YOU TIME IN THE END AND PRESERVE THE
INTEGRITY OF YOUR OPERATORY
2. Before Seating the Patient:
Revised: Apr-11
SECTION 10 – INFECTION CONTROL PROTOCOL
a. Put on a pair of plastic overgloves when arriving at the
cubicle
b. Prepare the cubicle for use in the manner described in the
previous section on Baseline Evaluation Protocol in Step
Three
c. Proceed to the supply cart and dispensary to pick up
instrument set-up, disposable supplies, gown, mask, and
equipment required for the procedure you are planning to
perform. Flush air/water syringe and handpiece hoses for 30
seconds in the sink. Remove and dispose of overgloves.
d. Wash hands. Turn faucets on and off with elbows when
possible to avoid cross-contamination
e. Set up protective covers and supplies in the manner
described in the Baseline Evaluation Clinic Protocol.
f. Set up the instrument tray for the procedure you are
planning to perform. In addition, obtain all items that will be
required for this procedure and set them out in the
appropriate zone
g. Cover instrument tray with patient napkin until patient is
seated
h. Arrange necessary patient treatment forms. Proceed to
reception area and call patient
3. Seat the Patient
a. Seat the patient, adjust the chair, and place patient napkin.
Review with the patient what is planned for this session and
the fees. Review medical history with the patient; request
any additional medical consultation; request a start check
from the instructor
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SECTION 10 – INFECTION CONTROL PROTOCOL
b. Request an anesthetic signature from an instructor if
required. Proceed to the dispensary for a disposable needle
and an anesthetic carpule
c. Wash hands for 1 minute with soap. Turn faucets on and off
with elbows when possible. Put on mask and protective
eyewear. Put on exam gloves in front of patient
d. Place a disposable tip on the air/water syringe. Attach
sterilized handpieces as needed for this session
e. Begin the planned procedure by administering the
appropriate anesthetic
f. Isolate the operative area by placing a rubber dam and
obtain a rubber dam instructor check
g. During the course of the planned procedure, obtain
instructor evaluation and signatures as required for that
procedure
h. IT IS EXTREMELY IMPORTANT THAT YOU ALWAYS
OVERGLOVE WHEN YOU:
i.
LEAVE THE OPERATORY FOR AN INSTRUCTOR
CHECK
i.
ii.
OBTAIN AN ADDITIONAL PIECE OF EQUIPMENT
iii.
GO TO THE DISPENSARY OR SUPPLY CART
iv.
GO INTO AN UNCONTAMINATED AREA
IT IS EXTREMELY IMPORTANT THAT YOU
CONSTANTLY CONSIDER THE POTENTIAL OF CROSSCONTAMINATION. Certain items are not autoclavable,
easily disinfected or disposable; these items should remain
uncontaminated. An example would be items, such as
medicament jars, that will be returned to an uncontaminated
storage area after the procedure has been completed.
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SECTION 10 – INFECTION CONTROL PROTOCOL
Keeping these items uncontaminated is accomplished by
ALWAYS OVERGLOVING when using these items and by
keeping contaminated and uncontaminated items
SEPARATED on the counter tops.
j.
All alginate, hydrocolloid, polyvinyl siloxane and polysulfide
impression material should be handled in the following
manner after removal from the mouth:
i.
Rinse the impression by filling with water and
dumping the water out three times
ii.
Spray liberally with the disinfectant solution presently
in use and place in a sealed baggie for at least 10
minutes
iii.
Rinse the impression again by filling with water and
dumping the water out three times
iv.
Alginate and hydrocolloid impressions should be
gently dried and the casts poured as soon as
possible. They should be placed back in the baggie
until the stone is set
v.
Polyvinyl siloxane and polysulfide impressions should
be gently dried and the casts poured according the
manufacturer’s directions
k. Put on a pair of overgloves. Finish required charting. Obtain
a final instructor evaluation and electronic signatures.
When the planned procedure is completed, remove the
patient napkin and saliva ejector and place them in the
debris bag attached to the instrument cart
l.
Remove overgloves and exam gloves and place in debris
bag. Remove mask and protective eyewear and dispose of
mask in debris bag.
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SECTION 10 – INFECTION CONTROL PROTOCOL
m. Dismiss the patient by walking patient to reception area
I.
After Dismissing the Patient
a. Wipe instruments carefully during the course of treatment to
eliminate or minimize scrubbing. If there is a need to scrub
instruments, place instruments in the sink, put on a pair of
heavy duty utility gloves and scrub/rinse as necessary to
remove blood and debris. Place on a clean paper towel. Put
on a pair of plastic overgloves. Return instruments to the
cassette properly sequenced
b. Prepare and clean the cubicle for its next use in the manner
described in the Baseline Evaluation Clinic Protocol
c. Clean and disinfect any equipment borrowed from the
dispensary by spraying with disinfectant and wiping with 2x2
saturated gauze or saturated paper towels. Return items to
the dispensary
d. Place each handpiece which were used in the mouth into an
appropriate cassette. Place all instruments and equipment
in an appropriate instrument box for sterilization
e. Clean and disinfect materials that are not autoclavable by
wiping with disinfectant-saturated 2x2 gauze or saturated
paper towels and allowing to air dry for 10 minutes
f. Remove overgloves and place in debris bag. Remove
debris bag and tie or tape closed before disposal. Place in
the proper receptacle
g. Place all instrument boxes in your clinic collection
containers after each patient for each clinic session (no later
than 12:15 or 5:15 or 9:00 PM for Thursday Night Clinic) for
sterilization
IV.
PROTOCOL FOR CLINICAL MATERIALS AND EQUIPMENT
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SECTION 10 – INFECTION CONTROL PROTOCOL
A. In the Protocol for Restorative Procedures, it is recommended that
certain items remain uncontaminated during the course of operative
and restorative procedures. The reason for this is that certain items
are not autoclavable, easily disinfected, or disposable. These items
also create a potential path for cross-contamination in the operatory.
There are two means of assuring that these types of items remain
uncontaminated during the course of operative and restorative
procedures. The first is to ALWAYS OVERGLOVE when using these
items. The second is to use the sections of the operatory that have
been designated as contaminated and uncontaminated areas and to
place and use items that should remain uncontaminated ONLY IN
THE UNCONTAMINATED AREA
B. The Protocol for Restorative Procedures presented an example of an
item that should always remain uncontaminated. The example was
medicament jars which will be returned to an uncontaminated storage
area after an operative or restorative procedure has been completed.
What follows below are other examples of items that should remain
uncontaminated. Remember that these are only examples and not a
complete list. Other items will undoubtedly come to mind as you
prepare the operatory for the procedure you are about to perform; all
items should be treated according to their designation as potentially
becoming contaminated or remaining uncontaminated during the
course of the scheduled procedure.
C. UNCONTAMINATED ITEMS (use overgloves):
1. Charts and radiographs
2. Triturator
3. Mediciments that have not been parceled out
4. Bulk disposables (paper supplies)
5. Restorative materials (i.e., Herculite kit)
Revised: Apr-11
SECTION 10 – INFECTION CONTROL PROTOCOL
6. Equipment box items (i.e., extra burs)
7. Temporary crowns
8. Pre-formed posts
9. Non-custom trays
10. Bulk impression materials
11. Other bulk disposables (i.e., retraction cord)
V.
Infection Control Protocols for Laboratory Procedures
A. All laboratory procedures involving appliances taken from or tried in a
patient's mouth are to be done in the clinical laboratories only. No
clinical work may be done in the preclinical laboratories
1. Masks and protective eyewear must be worn when performing
laboratory procedures that produce aerosols, such as grinding
2. Gloves should be worn when possible when performing
laboratory procedures. Students should exert caution when
using the lathes while wearing gloves. Handwashing is
essential before and after using gloves
3. Secure long hair and loose fitting clothing when performing
laboratory procedures to minimize the potential for crosscontamination and injury
4. A fresh sheet of counter-top paper should be used each time a
laboratory procedure is performed.
5. All spills should be cleaned up immediately and all equipment
not in use should be properly stored. When performing a
laboratory procedure that requires use of the polishing lathe, it
is essential that the following items be used:
a. FRESH PUMICE
b. A CLEAN DISPOSABLE TRAY
c. A STERILE RAG WHEEL
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SECTION 10 – INFECTION CONTROL PROTOCOL
6. Do not use pumice from the pumice pan or a rag wheel that is
already attached to the lathe. When performing laboratory
procedures at the polishing lathe, model trimmer, or grinding
bench, make sure the apparatus is properly shielded, and
remember to always use high-volume suction to minimize
aerosolization.
7. Common areas in the laboratory present a potential source of
cross-contamination. These include the sinks, lathes,
pneumatic curing device, quenching buckets, and bench tops.
Exert common sense and appropriate precautions when
working in these areas
8. An instructor should be consulted when problems or questions
arise in the course of performing laboratory procedures. If this
requires you to leave the laboratory, proper handwashing and
gloving techniques should be observed
B. Procedures Involving the Use of the Laboratories
i. Setting Up the Operatory
1. In preparing the operatory for a restorative procedure
that will involve the use of the laboratory, you will need
the following items:
i.
A plastic container partially filled with a specified
disinfectant. The container should be open, with
lid within easy reach (CAUTION -Be careful of
spills).
ii.
A denture brush placed within easy reach of the
sink
iii.
Items from the dispensary, the supply cart, or
your equipment box required to perform the
restorative procedure scheduled. These should
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SECTION 10 – INFECTION CONTROL PROTOCOL
include another denture brush and a pair of exam
gloves for working in the laboratory
A. Before Leaving the Operatory
a. Rinse the appliance under running water
b. Using the denture brush, SCRUB the appliance with
soap over the sink. Blood and saliva should be
thoroughly removed from any appliance that has
been in the mouth. Rinse the appliance again
c. Place the appliance in the container with disinfectant
and cover
d. Remove exam gloves, place in debris bag and wash
hands
e. Remove the appliance container to the laboratory
B. Before Seating the Patient:
a. Pick up the patient chart and Careslip from the
reception area
b. Put on a pair of plastic overgloves when arriving at
the cubicle
C. In the Laboratory
a. Set down the appliance container
b. Set up workspace for the laboratory procedure
c. Secure mask and protective eyewear, and reglove
d. Perform the laboratory procedure, using the
appropriate precautions to minimize the potential for
cross-contamination and injury
D. Before Returning to the Operatory
a. Rinse the appliance under running water
b. SCRUB with the denture brush over the sink until
clean
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SECTION 10 – INFECTION CONTROL PROTOCOL
c. Rinse the appliance again
d. Place the appliance in the container with disinfectant
and cover
e. Remove exam gloves and place in a trash receptacle
f. Remove the appliance container to the operatory
E. In the Operatory
a. After setting appliance container down, wash hands
and reglove
b. Remove appliance from container and rinse
thoroughly before returning appliance to the mouth
c. NOTE: RELINE AND IMPRESSION MATERIAL
SHOULD NOT BE SCRUBBED. ALL ALGINATE,
HYDROCOLLOID, POLYVINYL SILOXANE AND
POLYSULFIDE IMPRESSION MATERIAL SHOULD
BE HANDLED IN THE MANNER STIPULATED IN
THE PROTOCOL FOR RESTORATIVE
PROCEDURES. REFER TO THE PROTOCOL AS
NECESSARY (also available at dispensary window).
d. NOTE: IF THERE IS A NEED TO RETURN TO THE
LABORATORY WITH THE APPLIANCE OR
IMPRESSION, THE APPROPRIATE CLEANSING
PROCESS MUST BE REPEATED
e. NOTE: IF YOU ARE KEEPING THE APPLIANCE OR
IMPRESSION, THE APPROPRIATE CLEANSING
PROCESS MUST BE REPEATED BEFORE
REMOVING THE APPLIANCE OR IMPRESSION
FROM THE LABORATORY OR THE OPERATORY
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SECTION 10 – INFECTION CONTROL PROTOCOL
VI.
INFECTION CONTROL PROTOCOLS FOR RADIOGRAPHIC PROCEDURES
A. Protocol for Full Mouth Radiographic Series or Single Exposures
1.
Prepare the room for use:
a. Cover the patient chair and X-ray tube with plastic bags
provided. Tie the plastic bag on the X-ray tube above the
yolk
b. Cover the control box with plastic wrap from the roll
provided and attach it to the wall with a small piece of
tape
c. Cover the computer monitor and keyboard with plastic
bags
d. Place a plastic bag on top of the utility shelf
e. Obtain a sterilized set of instruments, a few cotton rolls
and Edge-eez tabs and place them on the utility shelf
B. Seat the Patient
1. Seat the patient and adjust the head rest for the patient.
Place the lead apron and thyroid shield on the patient. Put on
latex gloves, assemble the instruments and place a barrier on
the sensor, resting them on the covered utility shelf.
2. Begin the procedure by setting the first indicated exposure
3. Place the covered sensor in the patient’s mouth, adjust the
tube and make the exposure
4. Remove the sensor from the patient’s mouth, wipe it with a
paper towel to remove excess saliva, and check the plastic
barrier for damage. Replace the barrier if necessary. If the
image is not acceptable, ask the supervising instructor or
technician for assistance before continuing. Repeat the
process until the FMX series is completed
5. After the FMX is confirmed to be diagnostic by the supervisor,
dismiss the patient
6. Complete all necessary documentation in the patient’s
electronic chart and obtain final approval by the supervisor
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SECTION 10 – INFECTION CONTROL PROTOCOL
C. After Dismissing the Patient
1. While wearing gloves, remove the plastic bags from the
patient chair, X-ray tube, computer monitor, keyboard and the
control panel
2. Rinse the sensor holders with warm water and dry with a
clean paper towel. Place the holders in a new autoclave bag
3. Remove the sensor barrier and place the sensor in the holder
mounted on the wall. Throw out the plastic cover on the utility
shelf along with any disposable items that were used
4. With clean gloves use a paper towel with disinfectant to wipe
off the sensor and all surfaces that were touched during the
procedure. Throw out these gloves and towel(s).
5. Return the sensor holders in the new autoclave bag to the
appropriate location for sterilization. Wash your hands
thoroughly
VII.
STERILIZATION AND DISPENSARY PROCEDURES
A. Protocol for Sterilization and Dispensary Procedures
1. All sterilization personnel should wear gloves while performing
tasks or handling instruments. Gloves used to handle sterile
packs or sterile items must be uncontaminated
2. All sterilization personnel must use overgloves when
interrupting a sterilization procedure to hand out items from the
dispensary; and similarly, students must wear them when
interrupting an operatory procedure to acquire items from the
dispensary
3. Preparation of instruments for sterilization should take whatever
form necessary (i.e., wiping or scrubbing). Heavy utility gloves
should be worn while scrubbing instruments
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SECTION 10 – INFECTION CONTROL PROTOCOL
4. For wiping and scrubbing instruments prior to sterilization,
personnel should use either soap and water or Tricide solution
(Tricide is the solution presently in use).
5. Ultrasonic cleaning prior to sterilization is standard for all
instruments not subject to damage by this procedure.
ULTRASONIC CLEANING IS NOT RECOMMENDED FOR
HANDPIECES
6. For ultrasonic cleaning, the use of a Cavi-Clean and sodium
nitrate solution is standard. A five gallon mixture contains 150
milliliters of Cavi-Clean (liquid detergent), 250 grams of sodium
nitrate (solid crystal) and five gallons of water. THE
ULTRASONIC SOLUTION SHOULD BE CHANGED DAILY NO
MATTER WHAT THE VOLUME OF USE
7. The ultrasonic cleaner should always be covered with a lid
when in use
8. The following total cycle (e.g. heat, sterilize, exhaust and dry)
times and temperatures are standard for the sterilization of
instruments and other equipment. THE TOTAL CYCLE TIME
FOR STEAM AUTOCLAVES THAT ARE NOT AUTOMATIC
SHOULD INCLUDE A MINIMUM OF 20 MINUTES UNDER
PRESSURIZED STEAM AT THE RECOMMENDED
TEMPERATURE TO INSURE COMPLETE STERILIZATION
9. Steam autoclave 40 minutes 270 degrees F 132 degrees C
Hot air oven
60 minutes 320 degrees F 160 degrees C
Chemiclave
20 minutes 270 degrees F
Ethylene oxide gas
3 hour
sterilization cycle
132 degrees C
16 hour
aeration cycle
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SECTION 10 – INFECTION CONTROL PROTOCOL
10. The proper functioning of sterilization equipment must be
checked once per week by testing its ability to sterilize spore
test strips
11. ALL INSTRUMENTS AND EQUIPMENT THAT CAN BE
HEAT STERILIZED MUST BE
12. The DISINFECTION of instruments and other equipment that
cannot be sterlized must be done using a triphenolic
disinfectant (Tri-Cide) and one of the following techniques:
a. Soak in disinfectant for 10 minutes
b. Wipe with disinfectant with a 10-minute air dry
c. Wrap in disinfectant-soaked gauze for 10 minutes
13. SURFACE DISINFECTION should be done using either a
Tricide disinfectant is presently in use or sodium hypochlorite.
Tricide solution should be prepared according to the
manufacturer's recommendation. Sodium hypochlorite should
be prepared in a mixture of one part bleach to nine parts
water
14. All handpieces must be heat sterilized
15. All impression materials must receive a decontamination in
the manner stipulated in the Protocol for Restorative
Procedures before being removed to, or sent to, the
laboratory
16. All instruments and equipment must be properly sterilized or
disinfected before being presented to Central Supply for
repairs
VIII.
PROTOCOL FOR NEEDLESTICK EXPOSURES
A. FOR ALL PERSONNEL:
1. All needlesticks, instrument punctures and cuts
occurring during the course of treating patients or while
Revised: Apr-11
SECTION 10 – INFECTION CONTROL PROTOCOL
cleaning instruments SHOULD BE TREATED AS
POTENTIALLY INFECTIOUS
2. DO NOT MAKE A JUDGEMENT CONCERNING THE
SERIOUSNESS OF THE INJURY YOURSELF.
INSTEAD, IMMEDIATELY ADMINISTER FIRST AID
TREATMENT BY:
a. SQUEEZING (BLEEDING) THE WOUND
b. CLEANSING BY RUNNING UNDER TAP
WATER
c. WASH THOROUGHLY WITH SOAP AND
WATER
3. REPORT THE INJURY TO THE APPROPRIATE
CLINIC DIRECTOR, WHO WILL ASSIST YOU IN
REPORTING THE EXPOSURE AND OBTAINING
EMERGENCY CARE
4. AFTER REPORTING THE EXPOSURE TO THE
APPROPRIATE CLINIC DIRECTOR, ALL PERSONNEL
SHOULD IMMEDIATELY REPORT THE EXPOSURE
TO EMPLOYEE HEALTH SERVICES. THIS APPLIES
TO PREDOCTORAL AND POSTGRADUATE
PROVIDERS AS WELL AS FACULTY AND STAFF.
THE NUMBER TO CALL IS: 353-STIC (7842)
5. OCCUPATIONAL HEALTH SERVICES WILL ADVISE
YOU AS TO WHAT ACTIONS NEED TO BE TAKEN
NEXT. THEY WILL PROVIDE COUNSELING,
EMPLOYEE AND SOURCE TESTING, AND
TREATMENT, IF INDICATED
6. Faculty and staff will be asked to complete an
“Employee Injury Questionnaire” with the assistance of a
Revised: Apr-11
SECTION 10 – INFECTION CONTROL PROTOCOL
supervisor, within 24 hours of the exposure incident.
Students will be asked to complete a “Student Injury
Report” at Student Health Services before being treated
for the exposure
7. All personnel should read the “Infection Control
Needlestick Protocol” concerning how testing for HBV
and HIV infection will be done following emergency
treatment. All personnel should have a green “UCSF
HIV/HBV On-The-Job Exposure” card or a green “SFGH
HIV Counseling and Testing Service” card explaining the
employee exposure program. When possible, treatment
of the patient should be completed before leaving the
premises for emergency treatment
B. A “Confidential Clinic Incident Report” form must be
completed by the exposed student, faculty or staff member
with the assistance of the clinic staff or Clinic Director and
filed with the Office of Clinical Services within 24 hours of the
exposure incident
C. Student Health Service and Occupational Health Service will
follow needlestick protocols for possible HBV and HIV
infection developed by the Long/Moffitt Hospital Infection
Control Office. The treatments described below are a written
analysis of the needlestick algorithms. They may not be an
exact description of the treatment you receive; treatment
depends on the conditions surrounding your injury. They have
been included so that you will have some indication of what
may occur
D.
STUDENTS
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SECTION 10 – INFECTION CONTROL PROTOCOL
1. All students must provide documentation of Hepatitis B
antibodies, or are required to receive all or at least the
first two shots of the Hepatitis - B vaccination series at
the time of registration and enrollment at the UCSF
School of Dentistry. This policy is consistent with the
School's desire to protect both students and patients
from possible exposure to the Hep - B virus
E. Hepatitis B Status
1. Emergency treatment for students will be rendered at the
Student Health Service (MU-H005; x6-1281).
2. After emergency treatment of the injury at Student
Health, the student will be given immunoglobulin
3. Student Health will also draw blood in order to test for
antibody Hepatitis B surface antigen (anti-HBs) status if
the source (patient) is a known Hepatitis B surface
antigen positive (HBAG+).
4. If the anti-HBs test result is positive, the student has
been previously exposed to the Hepatitis B virus, and no
further treatment is necessary
5. If the anti-HBs test result is negative, the student will be
encouraged to begin the vaccine series within 7 days.
6. The Student Health Service will provide the vaccine
series free of charge to the student if the parenteral
exposure occurred while the student was involved in a
required clinical activity. Any student desiring the
vaccine series must sign the Informed Consent Form
provided by Student Health.
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SECTION 10 – INFECTION CONTROL PROTOCOL
7. If the student chooses not to take the vaccine series,
immunoglobulin should be administered by Student
Health Service one month after the exposure
F. HIV Status
1. Emergency treatment for students will be rendered at the
Student Health and Counseling Service ( Millberry
Union, 500 Parnassus Ave, level P8, room 005), 4761281 [email protected]
2. After emergency treatment of the injury, Student Health
will draw blood to test for the presence of HIV antibodies
(anti-HIV) upon written consent from the student. At the
time of the exposure, and after emergency treatment,
the student will be advised to follow the Hepatitis B
exposure protocol
3. This blood sample will be analyzed within 30 days and
the student will be notified of the test result by the
Student Health and Counseling Service
4. If the test result is negative, the student should present
himself at Student Health 6 months after the initial
exposure for another antibody test. If this test result is
negative, no further treatment is required
5. Counseling is available throughout the evaluation
process for students through the Student Health and
Counseling Center
G. Faculty and staff
1. Faculty and staff must go to the Emergency Department
at Long Hospital (L 138) for an evaluation following any
puncture injury or cut. I The Emergency Department will
have the faculty or staff member complete an Employee
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SECTION 10 – INFECTION CONTROL PROTOCOL
Injury Questionnaire and will examine the faculty or staff
member regarding
H. Hepatitis B Status
1. Emergency treatment for the faculty or staff member will
be rendered at the Emergency Department at Long
Hospital (L 138).
2. After emergency treatment, the Emergency Department
will give the faculty or staff member immunoglobulin
3. After treatment of the injury at the Emergency
Department, faculty or staff members will be directed to
go to the Occupational Health Service (EHS) 2186
Geary Blvd., Suite 103
4. Occupational Health Service will also draw blood in
order to test for anti-body, Hepatitis B surface antigen
(anti-HBs) status if the source (patient) is a known
Hepatitis B surface antigen positive (HBAG+).
5. If the anti-HBs test is positive, the faculty or staff
member has been previously exposed to the Hepatitis B
virus, and no further treatment is necessary
6. If the anti-HBs test is negative, the faculty or staff
member will be encouraged to begin the vaccine series
within 7 days. Faculty and staff members must sign a
written consent form if the vaccine series is desired
7. Workman’s Compensation will cover the cost of the
vaccine series for faculty and staff members if the
parenteral exposure is job related
8. If a faculty or staff member chooses not to take the
vaccine series, immunoglobulin should be administered
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SECTION 10 – INFECTION CONTROL PROTOCOL
one month after the exposure by the Employee Health
Service
I. HIV Status
1. Emergency treatment for faculty and staff members will
be rendered at the Emergency Department at Long
Hospital (L 138).
2. At the time of exposure, and after emergency treatment,
the faculty or staff member will be advised to follow the
Hepatitis B exposure protocol, and will be given an initial
shot immunoglobulin by the Emergency Department
3. After treatment of the injury at the Emergency
Department, the faculty or staff member will be directed
to go the Employee Health Service (EHS) at 2186 Geary
Blvd., Suite 103
4. The Employee Health Service will draw blood to test for
the presence of HIV antibodies (anti-HIV) upon written
consent from the faculty or staff member
5. If the source (patient) in known and in HIV positive, the
faculty or staff member will be asked by Occupational
Health to enroll in the Center for Disease Control’s
Needlstick Surveillance Survey, which the University
participates in. Enrollment in not mandatory
6. The blood sample will be analyzed within 30 days and
the faculty or staff member will be notified of the test
result by Employee Health
7. If the test result is negative, the faculty or staff member
should present himself/herself at the Occupational
Health Service 6 weeks after the initial exposure for
another antibody test. The Occupational Health Service
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SECTION 10 – INFECTION CONTROL PROTOCOL
will retest for HIV status at 3 months and 6 months if
required. If all the tests are negative, no further
treatment is required
8. Counseling is available throughout the evaluation
process for faculty and staff members through the
Faculty, Staff Assistance Program (FSSAP)
9. Long Emergency Department
L138
x 6-1037
Occupational Health Service 2186 Geary Blvd. Ste 103
885-7580
FSAP
IX.
1456-9th Avenue
x 6-6684
OTHER INFECTION CONTROL PROCEDURES
a. Protocol for Waste Disposal
i.
THESE PROTOCOLS ARE TO BE USED FOR ALL
PATIENTS
ii.
All students are reminded to attach a impermeable debris bag
to their instrument cart for disposable waste. All waste that
comes into contact with blood or saliva (e.g., gloves, cotton
rolls, tongue blades, disposable tips, etc.) will go into the
debris bag attached to the instrument cart. All disposable
needles will continue to be recapped using the “one handed
or scoop” method and placed in the red SHARPS container at
the end of the procedure for disposal by the dispensary staff.
At the end of the procedure, the debris bag will be tied or
taped shut and placed in the designated collection
bag/receptacle. Note: The debris bag does not need to be red
or have the biohazard symbol unless the procedure is
reasonably expected to generate a significant amount of
blood (e.g., soaked to the extent that it drips when squeezed).
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SECTION 10 – INFECTION CONTROL PROTOCOL
iii.
All other wastes (e.g., paper towels that were used to dry
hands, etc.) will be placed in the waste receptacle located
under the sink area
b. Protocol for Gown Use in the Predoctoral Clinics
i.
THESE PROTOCOLS ARE TO BE USED FOR ALL
PATIENTS
ii.
Gowns must be worn in patient treatment areas during all
dental procedures, including set-up and cleanup, and must be
changed after each clinic session when visibly soaked
through with blood or OTHER POTENTIALLY INFECTIOUS
MATERIAL. Gowns must be disposed of proper location, and
they must not be worn outside of the clinic areas, except for
transfer in between clinic areas in the Dental Clinics Building.
WHITE LABORATORY COATS MAY BE WORN ONLY FOR
CONSULTATION PROCEDURES THAT DO NOT REQUIRE
WEARING OF GLOVES, USE OF INSTRUMENTS,
PERFORMING BIOPSIES OR GENERATION OF
AEROSOLS
iii.
Clinic gowns are not allowed in the Patient Records Room,
offices, restroom facilities, Student Store, Student Lounge,
mail of conference rooms
iv.
Dental III, Dental IV and Dental Hygiene students will wear
one gown per clinic session (AM or PM). Dental and Dental
Hygiene faculty and assisting staff engaged in multiple patient
contacts are expected to use their best judgment and re-gown
as appropriate
v.
Gowns are not to be worn outside of patient treatment
areas. The general exception to this rule is when a student
needs to obtain a consultation from a faculty member who is
Revised: Apr-11
SECTION 10 – INFECTION CONTROL PROTOCOL
not located on the floor where the patient treatment activity is
taking place
vi.
Gowns are not to be worn when performing laboratory
work. The general exception to this rule is when a student is
engaged in a patient care activity that requires moving from
the operatory to the laboratory adjacent to the clinics to
perform a limited lab function related to that activity
vii.
White laboratory coats will not be worn under any other
circumstances beyond those described above. Dental I and II
students will be directed to draw a gown for patient care
activities as appropriate
viii.
Gowns will be distributed through the dispensaries at each
predoctoral clinic site. Students will select a clean gown at the
beginning of each clinic session and will be expected to turn
in the gown at the end of each clinic session at the
appropriate collection site
ix.
Blue gowns are to be worn by students and green gowns by
faculty. Gowns are available in each clinic area. After
completing scheduled patient care activities, all personnel
must return the gown to the proper used gown receptacle on
the floor from which they were obtained. Laundry carts will be
placed by the dispensary staff at appropriate locations
throughout the clinic floors for collection of used gowns
x.
Gowns will be available at the Parnassus Initial Intake and
Emergency clinics for student rotations at these sites
xi.
These gown protocols apply to all predoctoral activities on the
first, second and third floor clinics at Parnassus. At all other
rotations, gowns will be supplied to personnel and students
according to the requirements of the administrative cost
Revised: Apr-11
SECTION 10 – INFECTION CONTROL PROTOCOL
center responsible for activities conducted there. The use of
gowns will be governed by the rules those centers establish
xii.
The issuance and return of gowns will be on the honor
system. Theft and loss of gowns will be governed by
appropriate administrative action.
Revised: Apr-11
SECTION 11 – RADIATION POLICIES AND SAFETY PROTOCOLS
Oral Radiology Clinic
I.
LOCATION
A. The Oral Radiology Clinic is located on the first floor of the dental
clinics building at 707 Parnassus. The reception area is at the first
floor front desk; phone 476-5575.
II.
HOURS
A. This clinic is open from 8:00 AM to 5:00 PM, Monday through
Friday (except University holidays) to serve all clinics of the School
of Dentistry and licensed dentists outside of UCSF, who may
prescribe radiographic surveys for their patients. Intraoral surveys
are made by dental or dental hygiene students under the
supervision of faculty and staff. Intraoral, extraoral and special
projections are made by staff members.
III.
INITIAL EVALUATION
A. At the initial evaluation, the supervising faculty will prescribe
radiographs needed for baseline information in the predoctoral or
postgraduate clinics. Whenever possible, the radiographic survey
will be performed during the initial evaluation. The fee for baseline
radiographs will not exceed the fee for a full mouth survey.
Payment is required at the time of service.
IV.
PRESCRIPTION
A. All requests for radiographs in the predoctoral program must be
documented in the progress notes and signed by attending faculty
All predoctoral and postgraduate clinics must provide signed
prescriptions for radiographs. When proper prescriptions are not
available, no radiographic films may be performed. Students only
perform radiographs on patients of the Predoctoral/International
Dentists Clinics.
Revised: Apr-11
SECTION 11 – RADIATION POLICIES AND SAFETY PROTOCOLS
Oral Radiology Clinic
V.
TIME ALLOTMENT
A. The full mouth radiographic survey usually consists of 18-20
intraoral exposures. Radiographs may be performed by staff
technicians, dental or hygiene students. The length of the
procedure depends on the experience of the provider. Patients
should be encouraged by the appointment staff to arrive promptly
for appointments to allow completion of a radiographic survey
within the time allotted. All AM radiographic appointments must be
completed by noon, and all PM radiographic appointments by 5:00
PM. Under no circumstances may a student “cut” an assigned
class in order to perform radiographic procedures. Films must be
reviewed for diagnostic acceptability. When possible, retakes will
be performed immediately. In cases when retakes are not taken
immediately, the assigned student must perform retakes at the
baseline appointment.
VI.
FACILITIES
A. Most predoctoral clinic radiographic procedures will be performed
in the first floor facility. Use of the x-ray units on the second and
third floors is limited to endodontics, emergencies or limited films;
no full mouth surveys should be performed in the clinics.
B. There are several reasons for having this policy:
1. Unnecessarily tying up the x-ray rooms- the x-ray rooms are
intended for maximum use by student providers. Students
need to have the x-ray facilities primarily available for taking
radiographs for emergency and endodontic patients, and a
limited number of radiographs for POE patients.
Revised: Apr-11
SECTION 11 – RADIATION POLICIES AND SAFETY PROTOCOLS
Oral Radiology Clinic
2. X-ray film processors use- the clinic x-ray film processors
are intended to be used to develop a limited number of films
as quickly as possible to maximize patient care efficiency
and not place undue wear and tear on the equipment.
Processing a full-mouth x-ray film series is not conducive to
meeting this goal.
3. Quality control concerns- full-mouth x-ray surveys are to be
taken in the Oral Radiology service area in order to have the
staff provide instructions on proper mounting, labeling,
educational critiquing and recommendation for retakes (if
necessary).
VII.
ARCHIVES
A. Duplicates of all non-endodontic films are stored in the Oral
Radiology archives for at least seven years. Expired duplicates
are recycled.
VIII.
FILM AND TECHNIQUE
A. All non-endodontic films will be made with Ektaspeed double film
packs while using appropriate collimation. All films will be
processed to archival quality. One set of films will be mounted in a
properly labeled and dated mount and placed in the patient’s
dental record. The second set will be placed in a properly labeled
and dated duplicate envelope and left in the Oral Radiology Clinic
or collected by second floor dispensary staff for subsequent
transport to Oral Radiology archives.
IX.
ENDODONTIC FILMS
A. Endodontic films will be exposed with Ektaspeed single film packs.
Endodontic films must be properly mounted on the endodontic
Revised: Apr-11
SECTION 11 – RADIATION POLICIES AND SAFETY PROTOCOLS
Oral Radiology Clinic
case mount and stored in the patient’s dental record. Each film
should be properly dated on the mount. All endodontic working
films must be processed to archival quality.
X.
FILM RELEASE AND RECORDS
A. UCSF School of Dentistry physical and electronic records are the
property of the University of California Regents. Patients have
access rights to those records and the University has the
responsibility of protecting patient's confidential health information,
including radiographic images. Patients may request copies of
radiographs and other records by authorizing a Release of
Records request obtained from the Patient Records and
Registration Desk on the first floor. Release of films will be
documented in the Progress Notes. Students are not authorized to
release films to a patient. No radiographs should be taken from the
dental chart until presence of duplicate (second set) films has been
verified by radiology staff.
XI.
RADIOGRAPHIC EXPOSURE LOG
A. Purpose
1. The purpose of the log is to provide an easily accessible
summary of all actual radiographic exposures incurred by
patients during the course of treatment and evaluation
within the Predoctoral/International, Postgraduate
Periodontics and Postgraduate Endodontics clinics.
B. Prescriptions
1. Student-doctors should enter the date, number and type of
films requested in the appropriate columns of the Log. The
attending faculty should authorize the prescription by
Revised: Apr-11
SECTION 11 – RADIATION POLICIES AND SAFETY PROTOCOLS
Oral Radiology Clinic
placing signature and doctor number in column three.
Student-doctors should present the prescription to the
dispensary staff, who dispenses the authorized number of
films and make note of dispensation.
C. Actual Exposures
1. After exposing the film/s, student-doctors must enter the
actual number of films exposed, including retakes, in
column four. The attending faculty should confirm the
exposure/s by entering their signature and doctor number in
column five of the Log. Student-doctors must return any
unexposed, uncontaminated film to the dispensary.
D. Oral Radiology
1. If prescriptions for radiographs are documented on the NPV
form, the staff-person or student-doctor must document the
actual exposures on the Log as well as the Progress Notes
(Oral Radiology has stamp for this purpose).
E. Non-UCSF Radiographs
1. When films have been sent from another source and have
been accepted as diagnostic, they should be copied for the
UCSF archives and patient record. Therefore if the chart is
lost, the patient need not be re-exposed and the originals
may be returned to the previous dentist if requested.
F. Radiation Safety
1. The School of Dentistry Radiation Safety policy is contained
in Section 9, Health & Safety Policy.
G. Infection Control
Revised: Apr-11
SECTION 11 – RADIATION POLICIES AND SAFETY PROTOCOLS
Oral Radiology Clinic
1. The Infection Control Protocol for Radiographic Procedures
is contained in Section 10.
Revised: Apr-11
SECTION 12 – DENTAL EQUIPMENT/INSTRUMENT POLICIES
AND PROCEDURES
I.
STUDENT LOCKER ASSIGNMENT, STORAGE AND SECURITY
POLICY
A. All students are assigned locker space during their preclinical
and clinical activities. Students are responsible for maintaining
the security of these storage spaces during the assignment
period. Food items, unsterilized cassettes and instruments,
and printed patient information (Medical Information including
PHI) should not be stored in locker spaces. Appropriate
infection control guidelines should be implemented when
considering the types of items that are appropriate for storage
in locker spaces. Students are responsible for maintaining a
lock on their assigned locker spaces. Lost or stolen items will
need to be replaced by students and are not the responsibility
of Clinic Administration.
II.
MISSING/LOST INSTRUMENTS AND EQUIPMENT REPLACEMENT
POLICY AND PROCEDURES
A. Policy
1. Clinic Administration will assume responsibility for
instrument cassettes placed in ‘dirty’ storage bins or
handpieces submitted to the clinic dispensaries for
sterilization in the Central Sterilization Room. Thus, any
student’s equipment or instruments that are lost or
damaged during transportation, packaging or the
sterilization process will be replaced at no cost.
2. However, improper labeling, overloading and/or
placement of instruments in cassettes are often the
cause of damage or loss of instruments. Students are
Revised: Apr-11
SECTION 12 – DENTAL EQUIPMENT/INSTRUMENT POLICIES
AND PROCEDURES
responsible for properly labeling their cassettes with their
identification numbers and securing individual
instruments in the proper cassette type (e.g., the correct
instrument set-up for a restorative, perio or endo
cassette). Any deviation from standard instrument setup criteria may result in Clinic Administration not
replacing certain items. Also, any extra or special
instruments added to a cassette that are not on the
standard student kit issue list will not be replaced.
3. Handpieces must be placed in the handpiece cassette,
properly bagged, labeled and checked into the clinic
dispensary. Only one handpiece motor and appropriate
attachments per single cassette will be replaced (not two
handpieces per cassette).
4. A student identification log will be maintained by the
clinic dispensary assistants for all submitted handpieces.
B. Procedures to be Implemented for Improperly Submitted or
Missing Handpieces and/or Instrument Cassettes:
1. Policy:
a. Clinic Administration will assume responsibility for
instrument cassettes placed in ‘dirty’ storage bins
or handpieces submitted to the clinic dispensaries
for sterilization in the Central Sterilization Room.
Thus, any student’s equipment or instruments that
are lost or damaged during transportation,
packaging or the sterilization process will be
replaced at no cost
Revised: Apr-11
SECTION 12 – DENTAL EQUIPMENT/INSTRUMENT POLICIES
AND PROCEDURES
b. However, improper labeling, overloading and/or
placement of instruments in cassettes are often
the cause of damage or loss of instruments.
Students are responsible for properly labeling
their cassettes with their identification numbers
and securing individual instruments in the proper
cassette type (e.g., the correct instrument set-up
for a restorative, perio or endo cassette). Any
deviation from standard instrument set-up criteria
may result in Clinic Administration not replacing
certain items. Also, any extra or special
instruments added to a cassette that are not on
the standard student kit issue list will not be
replaced.
c. Handpieces must be placed in the handpiece
cassette, properly bagged, labeled and checked
into the clinic dispensary. Only one handpiece
motor and appropriate attachments per single
cassette will be replaced (not two handpieces per
cassette)
d. A student identification log will be maintained by
the clinic dispensary assistants for all submitted
handpieces
2. Procedures to be Implemented for Improperly Submitted
or Missing Handpieces and/or Instrument Cassettes
a. Handpieces
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SECTION 12 – DENTAL EQUIPMENT/INSTRUMENT POLICIES
AND PROCEDURES
i.
1. Handpieces that are not properly
bagged, labeled or checked in by a clinic
dispensary assistant (e.g., left in the ‘dirty’
instrument bin) will be logged, but held by
the Clinic Dispensary Supervisor. The
Clinic Dispensary Supervisor will then
contact the student and return the
unsterilized hanpiece cassette to the
individual. The student will be given
instructions on the proper procedure for
turning in handpeices for sterilization
ii.
2. For a missing handpiece, a student
must complete and submit a Missing
Handpiece/Instrument Claim Form
(Appendix ?) to the Student Store within
one week. The claim form can be obtained
from the Student Store staff. The student
must provide a serial number for any
missing handpiece and attachments.
Failure to provide serial numbers will
negate a search for the missing items by
the staff. Also, the student submitting the
claim form must send a global voice mail
message to all preclinical and clinical
students asking them to check for the
missing handpiece and if found, to return it
to the Student Store. Also, if a student
Revised: Apr-11
SECTION 12 – DENTAL EQUIPMENT/INSTRUMENT POLICIES
AND PROCEDURES
finds their missing handpiece on their own,
then the student is asked to report this fact
to the Student Store staff to close the
Missing Handpiece/Instrument Claim Form
request
b. Instruments
i.
For missing instrument cassettes or other
items, a student must complete and submit
a Missing Handpiece/Instrument Claim
Form with an itemized instrument list to the
Student Store within one week. Only
instruments that are part of the Student Kit
issue list will be considered for
replacement if not found by the staff. Also,
the student submitting the claim form must
send out a global voice mail message to all
preclinical and clinical students asking
them to check for the missing instrument
and if found, to return them to the Student
Store. If a student finds their missing
instruments on their own, then the student
is required to report this fact to the Student
Store staff to close the Missing
Handpiece/Instrument Claim Form request.
ii.
Otherwise, a follow-up visit to the Student
Store must be made to update the claim
status within two weeks of filing the claim
Revised: Apr-11
SECTION 12 – DENTAL EQUIPMENT/INSTRUMENT POLICIES
AND PROCEDURES
so that the staff can arrange for
replacement of instruments as appropriate.
Failure to return to the Student Store within
the specified time will result in dismissal of
the claim (unless there are extenuating
circumstances)
III.
MAGNIFICATION LOUPES POLICY
A. The UCSF School of Dentistry will provide one pair of
magnification loupes per student. The loupes are part of the
student kit equipment requirement and cost. Students cannot
elect to opt out of the loupes for any reason (e.g., student
already has magnification loupes)
B. Loupes will be ordered during the first three weeks of the ID3
and D3 year. They will be delivered approximately one month
later
C. After receiving the loupes, there is a 45 day grace period during
which time you can request an exchange of your loupes. You
will be allowed to switch from TTL to FLM or from FLM to TTL.
Also, you can switch from a titanium frame to an Oakley frame
or vice versa. The switch to an Oakley Frame will require an
additional charge. After 45 days, no more changes can be
made
D. No refund for loupes will be made by the School of Dentistry
E. Students are responsible for the security of their loupes. If the
loupes are lost or stolen, a student will need to replace them at
their own cost
Revised: Apr-11
SECTION 12 – DENTAL EQUIPMENT/INSTRUMENT POLICIES
AND PROCEDURES
F. A student will be required to sign a Magnification Loupes Policy
Form to acknowledge policy review and acceptance
Revised: Apr-11
SECTION 13– STUDENT STORE AND STERILIZATION
I.
GENERAL INFORMATION
A. Room Location D1046 Telephone: 514-1008 Hours: 8:00 a.m.4:00 p.m., M-F
B. Types of items sold: handpiece motors and components, hand
instruments, burs, endodontic files, instrument cassettes, denture
teeth, impression materials, safety goggles, gloves, gowns,
cavitron insert/sleeve and other student kit items.
C. Payment may be made by cash, check or credit card. There is a
charge of $35.00 for a returned check.
II.
STUDENT STORE SERVICES
A. Handpiece motor and components repair and maintenance
1. Student completes the Student Store Repair and Loaner
Form (see Appendix 13.II.A.1)
2. Student will be notified by e-mail communication when
his/her equipment is repaired
B. Handpeice motor and components loaner service
1. Student completes the Student Store Repair and Loaner
Form (see Appendix 13.II.B.1)
2. Loaner equipment (e.g., handpiece) is issued to a student
who is financially responsible for the equipment
3. Student will be notified by e-mail communication when
his/her equipment is repaired; the loaner equipment is be
returned in good working condition
C. Replace broken instruments under warranty
D. Hanau Articulator repair/parts replacement
1. In-house repair, mostly parts replacement
E. Process denture teeth orders
1. Student completes and submits denture teeth order form to
the Student Store after faculty and financial assistant
Revised: Apr-11
SECTION 13– STUDENT STORE AND STERILIZATION
approval; Verification of Payment Voucher is turned in with
the denture teeth order
2. Student picks up denture teeth order after 3 working days
F. Process lab case prescriptions and send to specific commercial
dental laboratories
1. Student obtains lab case prescription approval from faculty
and financial assistant
2. Student submits approved lab case prescription, fixed/rem
pros impressions and denture teeth (if lab is setting teeth for
dentures) to the Student Store
3. Student needs to provide the Student Store staff with the
following information: student name and I.D. number,
patient name and clinic account number, due date for lab
case
4. Student returns to the Student Store on due date to pick up
patient lab case
5. Any lab cases bypassing the Student Store window and
sent directly to a commercial lab, may subject the student to
disciplinary actions, including a fee assessment in the
amount of the laboratory fee
III.
CENTRAL STERILIZATION ROOM (CSR) SERVICES
A. Room location D1046 Telephone 476-5851 Hours: 8:00 a.m.- 4:30
p.m., M-F
B. All instrument cassettes and high speed handpiece motors and
slow speed handpiece motor components used during clinic
sessions are to be turned in and collected on each predoctoral
clinic floor to be processed by CSR. Instrument cassettes must be
clearly labeled with student provider numbers, but no tape on
cassettes. Handpiece motors and components that need sterilizing
Revised: Apr-11
SECTION 13– STUDENT STORE AND STERILIZATION
must be turned in and logged through the clinic dispensary
windows. After sterilization, bagged instrument cassettes and
handpieces are returned to the students’ instrument distribution
boxes on the 1st floor of the clinics building adjacent to the CSR.
Students are responsible for checking for the appropriate
sterilization color change on the sterilization bags.
C. The two sterilization methods used in CSR are :
1. Steam autoclaving- 45 minute sterilization cycle
2. Dry heat- 16 minute sterilization cycle
D. Sterilization of endodontic files: procedures for students,
dispensary and central sterilization personnel
1. New hand files
a. Staff- all new hand files are sterilized and packaged
with rubber stops installed and must be sorted and
placed in wedge-shaped sponges for student use
i.
Small sizes (06 to 25) in one sponge, all files
are of the same length(21, 25, or 31mm)
ii.
Large sizes (30 to 60) in a separate sponge,
all of the same length (21, 25, or 31mm)
2. New Nickel-Titanium rotary files
a. Staff- all new rotary files are sterilized and packaged
for student use
i.
One each of two taper sizes (.04, .06) are
placed in a small sterilization bag
ii.
All instruments are sterilized for clinic use
b. Students- Unused rotary files are to be returned to
the dispensary in a small pre-labeled sterilization
cycle bag for restocking and sterilization
3. Used hand files and Gates Glidden drills
Revised: Apr-11
SECTION 13– STUDENT STORE AND STERILIZATION
a. Students- all used hand files must be discarded in a
sharps container (not the sponge). Used hand files
are not reused for endodontic procedures.
b. Students- Gates Glidden drills may be reused if there
is no wear or distortion of the cutting blade. Gates
Glidden drills may be sterilized up to three
sterilization cycles; return to the clinic dispensary in
the pre-labeled sterilization bags indicating how
many sterilization cycles have been completed to
date
4. Used Nickel-Titanium rotary files
a. Students- these files may be reused up to 3 times if
there is no distortion in the cutting surfaces
b. Mark the colored shaft with a bur after each use and
discard after 3 uses
c. For processing and sterilization of files, clear all files
of debris by counter-rotating in alcohol dampened 2
X 2 gauze
d. Place the files in a small pre-labeled sterilization
cycle bag and return to the clinic dispensary staff to
arrange for sterilization
E. Student Instrument Distribution Boxes
1. All student instrument cassettes, handpiece motors and
components are placed in the student instrument
distribution boxes after sterilization. The student instrument
distribution boxes are located adjacent to the Central
Sterilization Room
Revised: Apr-11
SECTION 13– STUDENT STORE AND STERILIZATION
2. Students are expected to empty their instrument distribution
boxes on a daily basis and pick up important clinic
memorandums or administrative reports on a daily basis
3. The student instrument distribution box retrieval schedule is
listed as follows:
a. Monday- Friday
Open
8:00 a.m. to 12:00 noon
Closed 12:00 noon to 1:00 p.m.
Open
1:00 p.m. to 1:30 p.m.
Closed 1:30 p.m. to 2:00 p.m.
Open
2:00 p.m. to 6:00 p.m.
Revised: Apr-11
SECTION 14 – LABORATORY POLICIES AND PROCEDURES
I.
PREDOCTORAL CLINIC LAB POLICIES AND PROCEDURES FOR
REMOVABLE PROSTHODONTIC AND RESTORATIVE LAB WORK
A. Financial arrangements
1. Make sure patient has paid at least 50% of the procedure
fee. This is achieved by one of the following:
a. Cash patients: patient must pay 50% of the
procedure fee at the first crown or Fixed Partial
Denture (FPD or bridge) appointment. The
remaining balance is due at the delivery/cementation
appointment.
b. Insured patients, unapproved preauthorization or
non-covered benefit: Patients are same as cash
patients for this procedure
c. Insured patients, Preauthorization approved by
insurance. Most dental insurance policies pay 50%
for fixed (crown and bridge) and removable denture
(complete, partial and stayplates) treatment. The
patient can wait until insurance carrier preauthorizes
treatment to initiate treatment. Alternatively, the
patient can pay co-payment (usually 50%) instead of
waiting for preauthorization approval, so the work can
get started. Once insurance carrier approves
preauthorization, the carrier can pay the remaining
balance. If insurance carrier subsequently denies
claim or patient’s eligibility changes, the patient
becomes a cash patient for this procedure and is
responsible for remaining balance due at delivery.
d. Failure to obtain financial arrangements prior to
initiating restorative procedures is a violation of the
Revised: Apr-11
SECTION 14 – LABORATORY POLICIES AND PROCEDURES
student honor code and subjects the student to
disciplinary actions, including financial responsibility
for full restorative treatment fees
B. Removable prosthodontics
1. Denture Teeth Orders
a. Providers must make financial arrangements prior to
initiating any restorative procedures and/or sending
cases to commercial labs. (See Financial
Arrangements)
b. Fill out the Tooth Order Form. These are available in
the clinic forms storage cabinet near the student
mailboxes. Have your attending instructor
overseeing the case sign the form.
c. Bring this form to the Lab Case Window, Room
D1046 (Student Store).
d. The clinic staff will check the patient's AxiUm
payment record to verify a 50% fee payment or
approved insurance preauthorization request.
e. Allow three (3) working days for delivery
2. To Send Your Denture Set-Up For Commercial Laboratory
Processing, Order Framework Fabrication, etc.
a. Providers must make financial arrangements prior to
initiating any restorative procedures and/or sending
cases to commercial labs. (See Financial
Arrangements)
b. Third year students are required to perform every
step of denture fabrication, except resin packing and
casting RPD metal framework
Revised: Apr-11
SECTION 14 – LABORATORY POLICIES AND PROCEDURES
c. If there is no need to set the teeth, there is no need
to order the teeth. If the lab completes the setup, the
lab will provide the teeth specified on the prescription
d. Once you are ready to send your case to the lab,
complete the axiUm Removable Prosthodontics Work
Authorization Form (Forms tab, Dental Lab Forms).
Make sure the provider name and ID number are
entered on the form. Your instructor can help you fill
out the form so that it is clear and thorough to help
speed up the lab process. Attending faculty
authorization is mandatory to process any
prescription to the labs. Print the form, which will
accompany your casts.
e. Label the casts, denture set-ups, design casts with
the patient’s name. Place these items in 1-2 zip lock
bag(s). Be sure to label the bags with provider
name, student number, and the patient’s name.
f. Obtain a payment verification form from Financial
Assistant
g. Bring your pre-packaged case, payment verification
and work authorization forms to the Lab Case
Window, D1046. Denture processing cases will be
sent to either Plato Lab or Liberty Dental, which are
located in San Francisco. Denture processing
generally requires three (3) working days. RPD
framework orders are sent to Plato or Liberty Dental
Labs. They require ten (10) working days. Plato or
Liberty picks up every day at unspecified times.
Revised: Apr-11
SECTION 14 – LABORATORY POLICIES AND PROCEDURES
Students are responsible for checking on the return
of patient cases at the Lab Case Window.
LAB ITEM
WORKING DAYS
Stayplate
5
Complete Denture Processing
5
Removable Partial Denture Cast
10
Framework
h. You can communicate directly with the labs about
your case if needed. However, ALL LAB CASES
MUST BE SENT TO LABS THROUGH THE LAB
CASE WINDOW, D1046. No students or faculty can
send cases directly to the labs, bypassing the Lab
Case Window. Any lab cases sent to labs in violation
of this policy will not be paid for by the S/D. Students
and/or faculty are financially responsible for the
invoiced fees.
Plato’s: Rick Plato (415) 564-3411
Liberty: Dennis (415) 648-6609
i.
Lab Case Window Hours: 8:30 a. -12 Noon and 1:30
- 3:30 p
C. Crowns and fixed prosthodontics
1. Providers must make financial arrangements prior to
initiating any restorative procedures and/or sending cases to
commercial labs. (See Financial Arrangements, I., A.
above.)
2. Prep tooth/teeth; perform a clinically acceptable site master
impression; double-bite or opposing bite impression; bite
registration if taking an arch impression; select appropriate
tooth shade, etc. (all that applies to your case).
Revised: Apr-11
SECTION 14 – LABORATORY POLICIES AND PROCEDURES
3. Complete the axiUm Commercial Dental Lab Form (Forms
tab, Dental Lab Forms) and have it authorized by your
attending faculty. Be sure to include your choice of lab and
due date. (see below)
a. Due Dates - Allow the laboratory sufficient time to
complete the case. Student Store personnel are
trained and authorized to coordinate and track all
outgoing commercial laboratory cases in axiUm. All
laboratory prescriptions must include appropriate
working days for completion. Any changes must be
communicated through the Lab Case Window. The
following list includes various procedures and the
working days (Monday through Friday; add additional
day/s for recognized holidays) allowed for completion
of the procedures:
LAB ITEM
WORKING DAYS
Full Gold Crown
10
Porcelain and ceramic Crown:
10
Porcelain Fused to Metal Crown:
10
Fixed Partial Denture, three units, metal try-in:
15
Fixed Partial Denture, three units, finish:
15
Fixed Partial Denture, four or more units, metal try-in:
15
Fixed Partial Denture, four or more units, finish:
15
b. Any exceptions must be pre-approved by a clinic
director. If the date on the prescription does not allow
sufficient working time, the staff will make the
appropriate due date change and inform the studentdoctor via voicemail or axiUm email.
Revised: Apr-11
SECTION 14 – LABORATORY POLICIES AND PROCEDURES
c. Any changes to the due date caused by the
laboratory must be given to the student-doctor by
axiUm email and/or voice mail message. Rush jobs
must have pre-approval from the clinic director or is
the financial responsibility of the patient. (see below)
d. Specialized laboratory procedures increase the lab
cost and, therefore, must be borne by the patient.
These specialized procedures include the following:
PROCEDURE DESCRIPTION
CODE
Lab Rush Fee
L0140
Adapt Crown to Partial
L0141
Custom Shade
L0143
Shade Change
L0144
Custom Staining
L0178
Diagnostic Wax-up
L0161
Metal Occlusal
L0162
Porcelain Margin
L0163
Post Solder
L0177
Rest Seat Survey
L0179
Semi-Precision Attachment
Q0353
Precision Attachment
D6950
Guide Planes, Metal Crown
Q0355
Guide Planes, Porcelain Crown
Q0356
e. Failure to comply with these rules is grounds for loss
of academic credit for the procedure and other
disciplinary actions. Any additional charges from the
laboratory that result from failure to adhere to these
policies will be the responsibility of the student.
4. Print the authorized Lab form
Revised: Apr-11
SECTION 14 – LABORATORY POLICIES AND PROCEDURES
5. Obtain a payment verification form from Financial Assistant
6. Place your disinfected impressions, opposing casts, etc. in
1-2 plastic zip lock bag(s). These bags can be obtained
from the clinic supply cart. Label your impression and casts
with the patient’s name, provider name and student ID
number to avoid any possible confusion. Also, label the zip
lock bag
7. For Fixed cases, you have a choice of several commercial
labs, including The Toothworks, California Dental Arts,
HiTec Dental Ceramics and Porcelain Studios. The staff will
generate a logout note indicating the lab name and lab
case.
8. Bring your pre-packaged case, payment verification and
Commercial Dental Lab form to the Lab Case Window,
D1046. The staff will verify the patient's payment record
and log the case.
9. Fixed labs generally require ten (10) to fifteen (15) working
days. Please check for your completed lab case on the
designated due date. Once the student retrieves the case,
the staff will generate an axiUm note indicating the student
picked up the lab case.
10. You can communicate with the labs directly about your case
as needed. However, ALL LAB CASES MUST BE SENT
TO LABS THROUGH THE LAB CASE WINDOW, D1046.
Students or faculty can send cases directly to the labs,
bypassing the Lab Case Window. Any lab cases sent to
labs in violation of this policy will not be paid for by the S/D.
Students and/or faculty will be financially responsible for the
invoiced fees.
Revised: Apr-11
SECTION 14 – LABORATORY POLICIES AND PROCEDURES
DENTAL LAB
CONTACT PERSON – TELEPHONE #
The Toothworks
Albert - (415) 665-7171
Porcelain Studios
Andy - (650) 794-9889
California Dental Arts
Lonnie - (408) 255-1020
HiTec Dental Ceramics
Annie - (510) 791-1661
11. Lab Case Window Hours: 8:30 a. -12 Noon and 1:30 3:30 p.
12. GOLD ISSUE - With the exception of gold solder, the
Student Store no longer stores or distributes gold for
restorative work.
a. To request gold solder, obtain an authorization
(Request for Gold Issue) form, which requires
authorization from attending faculty. Return the
signed form to the Student Store for allocation of
the solder.
b. You will be issued a specific amount of gold,
which will be indicated on the request form.
Revised: Apr-11
SECTION 15 – DISPENSARY
I.
CLINIC DISPENSARY GENERAL INFORMATION
A. Location: room D2021
B. Hours of operation: Monday-Thursday
Friday
8:00 a.m.- 6:00 p.m.
8:00 a.m.- 5:00 p.m.
C. Opening of the X-ray rooms and supply carts is 7:30 a.m.
D. Closure of the X-ray rooms is 5:00 p.m., Monday- Friday
E. Closure of the supply carts is 5:30 p.m., Monday- Friday
F. Important policies and procedures
1. The clinic dispensary stocks items approved by Clinic Administration
in collaboration with School of Dentistry Departments. Instruments,
equipment, materials, supplies and medicaments that have not been
approved for use in the predoctoral teaching program are not available
in the clinic dispensary. Requests for item changes or additions are to
be directed to appropriate departments. Department representatives
will submit their requests to Clinic Administration for review and
approval.
2. Most supplies and materials needed by students for patient care
activities are located in mobile clinic floor carts and are restocked
periodically by the clinic dispensary staff (see disposable supplies,
endo, pros and restorative carts itemized lists, Appendix 15.I.F.2).
Staff opens the carts for student access during clinic sessions.
3. Disposable supplies are not to be “stockpiled” at individual cubicles.
Judicious use of supplies and materials is important in containing
clinic costs.
4. Students are required to complete the Clinic Dispensary Request
Form (see Appendix 15.I.F.4) with faculty signature to obtain local
anesthetics, medications (e.g., antibiotics, acetaminophen, ibuprofen),
nitrous oxide equipment and certain equipment items (e.g., electro-
Revised: July-11
SECTION 15 – DISPENSARY
surgery unit, crown and bridge remover kit, Ligmajet for periodontal
ligament injections)
5. Students are required to complete the Endo Supply/Equipment
Request Form (see Appendix 15.I.F.5) to request an endo procedure
set-up tray
6. Students are required to submit a completed and signed Extraction
Checklist (see Appendix 15.I.F.6) to request an extraction kit
7. All clinic dispensary items borrowed by students must be returned
before the following closing times:
Monday- Thursday
12:00 noon (morning session)
5:30 p.m. (afternoon session)
Friday
12:00 noon (morning session)
4:45 p.m. (afternoon session)
After 6:00 p.m. clinic dispensary item pick-up, please follow this
protocol:
a. Properly wipe equipment with surface disinfectant
b. Legibly print your student identification number on the
sterilization bag containing the particular item (e.g., instrument
cassette)
c. Call the Central Sterilization Room at ph # (415) 476-5851 to
request an item pick-up
d. Once you return the borrowed item, your student ID card will
be returned to you
e. You name will be cleared from the clinic dispensary borrowed
item log on the following day
8. Borrowed items must be properly checked in by clinic dispensary staff.
Also, returned items must be cleaned and disinfected in accordance
with infection control protocol. Any items needing additional
Revised: July-11
SECTION 15 – DISPENSARY
disinfection or required sterilization must be clearly identified to clinic
dispensary staff.
9. The cost of replacing items not returned or damaged will be billed
directly to a student.
10. The clinic dispensary staff will issue hypoallergenic gloves to students
and faculty who are allergic to or unable to wear latex gloves or whose
patients have latex allergies.
11. The clinic dispensary staff maintains vigilance over a limited number
of dental/medical reference books, which are located on the south
side of clinic A. If reference books are borrowed, students and/or
faculty are asked to return the reference material to the home location
in a timely manner.
12. Most clinic forms now reside electronically in Axium, but there are
some hard copy forms located in metal file holders adjacent to the
student mailboxes on the 2nd floor of the predoctoral clinics. The forms
include the Clinic Dispensary Request, treatment planning
worksheets, extraction kit checklist, extraction postoperative
instructions, Planned Absence and Administrative Action forms.
Students are asked to inform the dispensary staff when forms need to
be replenished.
13. Dispensing patient oral hygiene aids:
a. As part of preventive education and to augment oral hygiene
instruction, students may give a toothbrush, floss, floss holders,
toothpick holder, toothpicks and fixed bridge floss thread aids
as needed (usually when plaque control instruction and
periodontal treatment is provided).
b. Please use prudent judgment in helping to conserve oral
hygiene aids and products.
Revised: July-11
SECTION 15 – DISPENSARY
c. Interproximal brushes and refills may be purchased by patients
for a small fee.
14. Dispensing caries management products:
a. Caries management products are prescription items that
require faculty approval. Current available products include
Control Rx (fluoride toothpaste), Peridex (chlorhexidine),
fluoride varnish, MI paste (calcium phosphate), Xylitol mints
and Xylitol gum.
b. The Caries Prevention Package (saliva bacterial test, 2 tubes of
fluoride toothpaste, 1 bottle of chlorhexidine, 1-2 unidose
packets of fluoride varnish) and individual caries management
products must have the appropriate Axium transaction code
charged out and approved by faculty.
c. The Caries Prevention Package will be dispensed by the
reception staff on the 2n floor and individual caries
management products for cash/Denti-Cal Program patients
from the clinic dispensary. Cash patients are expected to pay
for products on the same day that products are dispensed
15. The following items need to be properly treatment planned, approved
by faculty and proof of patient payment provided to the dispensary
staff before dispensing: occlusal guard material and teeth bleaching kit
G. Clinic dispensary guidelines and student responsibilities:
1. Students are required to wear their name tag with ID number when
visiting the clinic dispensary to check out items
2. Be ready to inform the dispensary staff of your cubicle location
3. In order to avoid repeated trips to the dispensary, carefully prepare a
list of the equipment and supplies that you will need for each clinical
procedure
Revised: July-11
SECTION 15 – DISPENSARY
4. Allow enough time for properly returning items to the clinic dispensary.
The dispensary staff is required to follow strict guidelines for logging
out and logging in items
5. Students are expected to exhibit professionalism and common
courtesy when waiting in line for clinic dispensary items
6. Do not bring patients to the dispensary windows
7. Your student ID card will be collected when you check out equipment
from the dispensary. Your ID card will be returned when the checked
out equipment is returned in good condition. The following equipment
requires student ID card collection: ATP saliva bacterial test meter,
Obturator, Apex Locator, Surveyor, pressure pot, pulp tester, TransIlluminator, cameras, endo microscope, Diagnodent, Electro-Surgery
Unit, nitrous oxide and laser equipment. Equipment must be returned
by 5:30 p.m. on Monday-Thursday and by 4:45 p.m. on Friday
8. Diagnostic equipment (e.g., Diagnodent, pulp tester, ATP saliva
bacterial tester, Trans-Illuminator) must be returned to the clinic
dispensary as soon as the patient diagnosis is completed to make
these items available to other students
9. Students are responsible for returning equipment to the dispensary
after every clinic session. Equipment is not to be left out on the clinic
floor during the lunch break. If patient treatment will continue in the
afternoon with the same equipment, then the staff may be asked to
store the equipment inside the dispensary until needed again in the
afternoon clinic session
10. Equipment for overnight use requires a written approval from a
Predoctoral Clinic Director
11. If a patient cancels or does not show for an appointment, then the
student must immediately return checked out equipment to the
dispensary
Revised: July-11
SECTION 15 – DISPENSARY
12. Students are responsible for reporting missing, malfunctioning or
broken equipment to the dispensary staff in a timely manner. Also,
please report X-ray room, chair equipment and Axium computer
problems to the dispensary staff
13. The student checked out equipment log is reviewed on a daily basis.
Any equipment or other items that are not returned will be reported to
the dispensary supervisor. A courtesy e-mail message will be sent to a
student requesting that the missing item be returned to the
dispensary. If the item is not returned, then a replacement fee will be
assessed to the student by the Student Store supervisor. Students will
be held financially responsible for lost or broken equipment.
H. Student reminders for sterilization and infection control procedures:
1. Hand pieces and X-ray instruments are collected at the dispensary
and returned to your lockers after sterilization
2. The outside of the sterilization bag must be properly labeled with your
ID number, clearly marked and legibly printed. Place the instrument
tray facing toward the clear side of the sterilization bag. This helps the
dispensary staff to accurately log the number of items inside a
cassette
3. Follow the clinic’s infection control guidelines at all times. Package the
contaminated instruments at your cubicle, but not on the tops of clean
carts
4. Wear over-gloves when you approach the dispensary windows
5. At the end of your clinic session, properly break down your cubicle
operatory by removing all disposable barrier coverings. Any unused
supplies must be returned to the disposable supply carts
Revised: July-11
SECTION 15 – DISPENSARY
6. Spray and wipe all contaminated surfaces. Give special attention to
the removal of alginate and/or stone inside and outside the sink area
7. Spot checks for proper cubicle closure and cleaning are conducted by
the dispensary staff on a daily basis. Students not following the
infection control guidelines will be counseled
8. Students must comply with all gown restriction notices (“No gowns
beyond this point”) posted at the perimeters of the clinics. Students
should remove and store gowns at their cubicle when retrieving and
escorting patients to and from the waiting room, financial assistant,
restrooms and transporting patients between floors.
9. Dispose of your contaminated clinic gown in the metal receptacles
located throughout the clinic floors
10. At the end of each clinic session, raise the patient chair to an upward
position, turn the power off and place the foot pedal (with a new bag)
on top of the chair
Revised: July-11
SECTION 16 – OPERATORY AND LAB MAINTENANCE PROCEDURES
I.
GENERAL POLICIES
A. Students must do the following before leaving a cubicle after
treating a patient:
1.
Turn off master and water switches
2.
Empty water bottle and replace empty to unit
3.
Turn off air-cool switch and suction
4.
Make certain countertops are clean, especially of all
waxes
5.
Upright chair and elevate to its highest position
6.
Line up arm of overhead light parallel with arm on chair
7.
Remove headrest covers and plastic from light handles
8.
Remove all suction tips
9.
Clean and wipe down all areas and dispose of waste in
accordance with the Infectious Control Protocol
10.
Do not leave unused clinic supplies (gauze, suction tips,
etc.) in the operatory
II.
DENTAL EQUIPMENT MAINTENANCE AND REPAIR
A. The Maintenance and Repair Unit is responsible for maintaining
and repairing clinical and lab equipment. Information pertaining to
the proper operation of all equipment can be obtained by
contacting the Maintenance and Repair Unit (502-8408).
B. Students should report problems with clinic equipment (light,
chairs, and units) to clinic dispensary personnel. Laboratory
equipment (ovens, lathes, etc.), and building (plumbing, electrical,
elevator) problems should be reported to the Facilities Manager (65848) or the Maintenance and Repair Unit (502-8408)
C. Staff keeps the labs stocked with supplies.
D. Students are hired to keep the laboratory areas clean.
Revised: Apr-11
SECTION 17 – STATE BOARD EXAMINATION INFORMATION
I.
PROTOCOL FOR DENTAL LICENSURE EXAMINATION PATIENT
EVENING SCREENING
A. Designated student coordinator checks in patients as they arrive at
the school for screening (5:30 - 7:00 PM); patients are asked to
wait in the patient lounge on the 2nd floor of the clinics building
B. Patient completes the Limitations of Screening Evaluation Form
with abbreviated medical history section. Patient signs the legal
disclaimer on the screening form noting that a general assessment
of obvious dental needs will be made; the student is not performing
a comprehensive oral examination
C. A student escorts a patient to a designated examination area in
clinic A or B
1. Explain to the patient that a cursory evaluation will be
performed (not a comprehensive examination).
2. Medical history is reviewed; assess the patient’s need for a
medical consultation (e.g., antibiotic prophylaxis needed for
a particular medical condition). Also, please note that the
Dental Licensure Examiners may, at their discretion, reject a
patient who in the opinion of at least two examiners has a
condition which interferes with evaluation or which may be
hazardous to other patients, candidates or examiners. A
hazardous condition includes, but is not limited to,
contagious hepatitis, active herpetic lesions, acute
periodontal or periapical abscesses, or necrotizing
ulcerative gingivitis. Also, patients with severe hypertension,
history of receiving intravenous bisphosphonates, severe
diabetes requiring insulin injections, latex allergy, or a
history of heart attack, stroke, cardiac surgery in the past six
months are not acceptable
Revised: Apr-11
SECTION 17 – STATE BOARD EXAMINATION INFORMATION
3. Make sure the patient has read and signed the Limitations
of Screening Evaluation Form
4. Evaluate the patient. Record your findings on the Patient
Screening Assessment Form. If the patient does not qualify
for further screening by digital X-rays and is not interested in
treatment at the school or private practice, thank the patient
for their participation and release them.
5. If the patient has dental licensure exam potential, obtain a
faculty signature for radiographs (generally 2-4 BW’s and/or
limited periapical radiographs)
6. Proceed to an x-ray room to take faculty approved
radiographs
7. Clean the x-ray room for the next student
8. Escort the patient back to the clinic screening area
D. Review radiographs with the supervising faculty faculty; determine
if the patient is suitable for the Dental Licensure Examination
E. Based on your cursory evaluation, document the patient’s obvious
dental problems on the Patient Screening Assessment Form
F. Brief the patient on your next recommendation:
1. If the patient is not suitable for the Western Regional
Examination Board (WREB), but wants dental care at The
School of Dentistry, refer to a school clinic (e.g., predoc,
AEGD, P.G. Pros/Perio, etc.). If the patient is interested
and qualifies for comprehensive care in the predoc clinic,
supervising faculty will give the patient screening forms
records to Dr.Silva for registration, assignment and
scheduling of patient with the appropriate clinic.
2. Refer to a private dentist, San Francisco Dental Society
(phone # 421-1435) or other city clinics; Dental Care
Revised: Apr-11
SECTION 17 – STATE BOARD EXAMINATION INFORMATION
Resources list available to give to the patient. Give the
screening forms to the supervising faculty.
3. Accept for comprehensive care in the predoctoral clinic to
prepare the patient for WREB. During regular clinic hours,
take the screening forms to the Registration Desk (1st
floor); Appointment Assistant will register the patient with a
special WREB code; account number generated, chart
made, assignment and scheduling completed for you
4. If the patient is to participate on the periodontal component
of the WREB, you may take an FMX at the special fee of
$10.00 (do not schedule patient with a radiographic
technician, this is your responsibility).
G. Clean your exam chair/cubicle (remember infection control
guidelines).
H. See the student coordinator for your next patient
I. Important! Please do not promise potential WREB patients free
dentistry in the school clinics. The patient or student must pay for
treatment (regular clinic fees). Also, please do not promise your
patient free dentistry during the WREB. There is always the
possibility that the Examiners will not accept your patient for the
exam. In the past, some patients have complained that a promise
of free dentistry was not kept and they want the school to
compensate them. The school cannot compensate patients,
rather you should inform your patients that you will assume
financial responsibility for their care. Alternately, you may wish to
state to your patients that no guarantee of acceptance or free
treatment on the WREB can be promised.
J. Student Coordinator Duties And Responsibilities
Revised: Apr-11
SECTION 17 – STATE BOARD EXAMINATION INFORMATION
1. Checks in with supervising faculty at 5:30 pm, sharp!
Faculty orients student coordinator
2. Checks to make sure there is an adequate supply of WREB
screening forms (photocopy at class expense).
3. Organizes clip boards, screening forms, writing implements
for patients.
4. Puts up signs directing patients to the 2nd floor waiting area
5. Checks in patients as they arrive at the school for screening
(5:30-7:30 pm); screening log information is completed for
each patient
6. Briefly orients patients on screening format (what to expect).
7. “Assigns” patients to students participating in screening
session (make sure screening form is complete and signed
by patient).
8. After each patient screening, make sure the patient has
been referred for continuing dental care (give them Dental
Care Resources list or refer to a school clinic). Some
patients may not be interested in a referral, but do thank
them for their participation in the screening session
9. At the end of the patient screening session (7:30 PM):
a. collect all clip boards, screening forms, writing
implements; place in designated storage box
(see
supervising faculty)
b. remind students to clean chairs and cubicles; pick up
debris/waste as necessary if a student leaves it
behind
c. give completed patient screening log and forms to
supervising faculty
Revised: Apr-11
SECTION 17 – STATE BOARD EXAMINATION INFORMATION
II.
PROTOCOL FOR WREB PATIENT SCREENING IN THE
COMPREHENSIVE CARE CLINICS
A. If you wish to bring friends, relatives, or acquaintances to the
school during regular clinic hours for WREB screening, please use
the following protocol:
1. Contact Drs. Silva, Podesta, Le, Djordjevich, Plies, Jenson,
Herbert, White, Kudler, Ino, or Parisi to arrange a “private”
State Board screening.
2. On the day of the patient screening, pick up the WREB
screening forms from the Registration Desk Appointment
Assistant (1st floor).
3. Escort the patient to an available examination chair (during
your comp care time).
4. Patient completes the Limitations of Screening Evaluation
Form with abbreviated medical history. Patient signs
disclaimer on form noting that a general assessment of
obvious dental needs will be made; it is not a
comprehensive exam
5. View patient’s medical history with supervising faculty.
6. Examine the patient. Record your findings on the Patient
Assessment Form. If the patient has no WREB screening
potential and is not interested in treatment at the school or a
referral to a private dentist, thank the patient for their
participation and release them.
7. If the patient has WREB potential, obtain faculty signature
for radiographs (generally 2 BW’s and/or limited PA
radiographs). Remember, if the patient is to participate on
the WREB Periodontal Clinical Examination, you may take
an FMX for the special fee of $10.00 (do not schedule
Revised: Apr-11
SECTION 17 – STATE BOARD EXAMINATION INFORMATION
patient with a radiographic technician, this is your
responsibility).
8. Pick up XCP instruments and x-ray film (class paid) from a
radiographic technician; take the appropriate radiographs;
clean the x-ray room for the next student; return XCP
instruments (after packaging in sterilization bag) to the nonsterile plastic tub (in the x-ray viewing room); develop the
films, mount, label and file the duplicate x-rays
9. Discuss the radiographs with faculty; determine if the patient
is suitable for WREB. You may give the patient the
radiographs if the patient is not suitable for the WREB.
10. Based on your cursory examination, document the patient’s
obvious dental needs on the Patient Assessment Form
11. Return the screening forms to the Registration Desk
Appointment Assistant (first floor). Decide if the patient is to
be accepted for comprehensive care. Register patient;
special WREB code given; chart made
12. Provide Comprehensive Care - baseline exam and regular
clinic policies and protocols are followed in preparing the
patient for the WREB Exam. The screening forms will be
placed in the patient chart.
B. Important! Please do not promise potential WREB patients free
dentistry in the school clinics. The patient or student must pay for
treatment (regular clinic fees). Also, please do not promise your
patient free dentistry on the WREB. There is always the
possibility that the Examiners will not accept your patient for the
WREB Exam. You must assume full responsibility for your
patient’s care.
Revised: Apr-11
SECTION 17 – STATE BOARD EXAMINATION INFORMATION
Revised: Apr-11
SECTION 17 – STATE BOARD EXAMINATION INFORMATION
UNIVERSITY OF CALIFORNIA SCHOOL OF DENTISTRY
LIMITATIONS OF SCREENING EVALUATION FOR DENTAL
LICENSURE EXAMINATION
The screening evaluation is not a complete dental examination and is not intended to be a substitute for a
detailed a comprehensive or periodic oral examination. This service is provided at no charge.
The screening evaluation consists of an evaluation of your medical and dental history, a preliminary visual
assessment and possibly a limited radiographic (x-ray) evaluation. Radiographs will only be taken of those
areas which may be treated during the dental licensure examination. If a full mouth x-ray survey is required,
then the patient fee is discounted to $20.00 (if taken by a student). No other types of x-rays are included in
this discount offer.
The screening evaluation consists of an evaluation of your medical and dental history, a preliminary visual
assessment and possibly a limited radiographic (x-ray) evaluation. Radiographs will only be taken of those
areas which may be treated during the dental licensure examination. If a full mouth x-ray survey is required,
then the patient fee is discounted to $20.00 (if taken by a student). No other types of x-rays are included in
this discount offer.
All screening evaluations will be supervised by a member of the faculty. All findings will be discussed with
you, emphasizing your general dental needs. Information will be available about locations which provide
comprehensive and/or emergency dental care.
If your needs meet the criteria established by the dental licensure examiners , one or more of the following
services may be performed during the exam: evaluation of periodontal needs and cleaning of some of your
teeth, placement of a silver filling or a composite (resin) filling. You and your candidate should agree on a
means to complete any remaining periodontal and/or restorative treatment. Provision of services at no charge
during the licensure examination depends on the availability of candidates as well as acceptance of your
treatment needs by the licensure examiners. Therefore, the UCSF School of Dentistry cannot assume
responsibility or liability for the quality of treatment rendered, or for a patient not being accepted by the
examiners or promises of acceptance given by its student graduates.
After the screening evaluation, there will be charges for all services provided at the UCSF School of Dentistry
in preparation for the licensure examination and for any needed treatment after the examination
I have read and understand this statement of limitations. I accept and understand that my participation in this
screening program does not guarantee me treatment of any kind. I understand that only treatment actually
done during the licensure examination is at no charge, and only if I am accepted as a patient by the licensure
examiners.
(Signature of Patient or Guardian)
(Date)
NAME
DATE OF BIRTH _______________________
____
ADDRESS
HOME PHONE_________________________
EMPLOYER_____________________
WORK PHONE__________________________
Revised: Apr-11
SECTION 17 – STATE BOARD EXAMINATION INFORMATION
Revised: Apr-11
SECTION 17 – STATE BOARD EXAMINATION INFORMATION
Revised: Apr-11
SECTION 18 – SUMMER SESSION ONLY/LIMITED STATUS STUDENT
I.
SUMMER SESSION ONLY/LIMITED STATUS STUDENT
A. A summer session only or limited status student is a recent graduate
of the UCSF School of Dentistry who has not yet passed a licensure
examination, or who has been unable to take the WREB or another
licensure examination for California. Recent graduates with either of
these designations are accepted by the School for limited patient care
activities in the Predoctoral Clinic and/or limited access to the
simulation/technique labs (summer session only is applicable to
summer sessions I, II or III; limited status is applicable to fall, winter
and/or spring quarters).
B. In an effort to help facilitate the licensure of UCSF School of Dentistry
graduates, the School will attempt to accommodate as many
graduates as possible to help them maintain their clinical skills in
preparation for the licensure examination. Students may be asked to
participate in patient care and/or teaching activities to maintain clinical
competency.
C. Policy:
1. A graduate seeking access to Predoctoral Clinic or simulation
lab shall submit a request to the Associate Dean for Clinic
Administration prior to making a formal application to the
School. Acceptance shall be based on space accommodation
considerations, faculty resources, Predoctoral Clinic needs and
other relevant factors.
D. Procedure:
1. The graduate submits a request to the Associate Dean for
Clinic Administration to be considered for a summer session
only or limited status position in the Predoctoral Clinic or
simulation lab
Revised: Nov-11
SECTION 18 – SUMMER SESSION ONLY/LIMITED STATUS STUDENT
2. After approval by the Associate Dean, the graduate must
register for a particular time period with the Registrar:
a. A formal application to the School of Dentistry is made in
Educational Support Services, room D-4010, through the
Coordinator of Student Academic Records
b. A registration packet is obtained from the Registrar’s
Office and completed
c. The graduate must provide documentation of current,
valid BLS certification to the Coordinator of Student
Academic Records (D-4010)
d. The appropriate fees are paid
e. A registration identification card is issued
3. After registration, the graduate must report to a designated
Clinic Director who will schedule and coordinate clinic activities
4. The graduate must be supervised by a faculty member and
obtain faculty electronic signatures for all patient care activities,
and report to a designated Clinic Director on a predetermined
schedule who will monitor their clinic activities
5. The graduate must agree to abide by all existing Predoctoral
Clinic and departmental policies and protocol as a condition for
having access to clinics, lab and patients
6. The graduate may be asked to participate in an appropriate
orientation to be eligible for patient care activities
7. The decision to extend the stay of a graduate for more than one
summer session or quarter is the prerogative of the Associate
Dean for Clinic Administration. The graduate must obtain clinic
administrative clearance at the end of their tenure at the School
of Dentistry
Revised: Nov-11
SECTION 19 – UCSF POLICY ON SEXUAL HARASSMENT
I.
UCSF POLICY ON SEXUAL HARASSMENT
A. http://ucsfhr.ucsf.edu/index.php/pubs/hrguidearticle/chapter-16sexual-harassment/
Revised: Apr-11
Dean
Depts
•Orofacial Sciences
•Oral & Maxillofacial
Surgery
•Preventive & Restorative Dental Sciences
Director of
Health & Safety
Divison Chairs/Department Chairs
QA Committee
PCC Course
Directors
Clinic Directors
QAIR
Forms
Implant CQI
Committee
Clinic Administrative Services
Outcome
of Care
Patient Satisfaction Surveys
Chart Audits
Risk Mgmt Cases and Patient Complaints
Students Correct Chart Audit
Deficiencies
(a) Feedback to Division Chairs and Program Directors to investigate and respond to QA Committee
‐ why did incident occur?
‐ how was it managed?
‐ how will it be prevented
Revised:11/8/2011
(a)
QAIR
Forms
University of California, San Francisco
School of Dentistry
LABORATORY & CLINICS
POLICIES & PROCEDURES MANUAL
APPENDIX
APPENDIX 2.IV.C.1
APPENDIX 2.IV.C.1
APPENDIX 3.II.A.1
APPENDIX 3.II.A.1
APPENDIX 3.II.A.1
APPENDIX 3.II.A.1
APPENDIX 3.II.A.2
APPENDIX 3.II.A.2
APPENDIX 3.II.A.3
APPENDIX 3.II.A.4
APPENDIX 3.II.A.5
APPENDIX 3.II.A.5
APPENDIX 3.II.A.6
APPENDIX 6.IV.C.4
APPENDIX 8.IV.A
APPENDIX 8.IV.A
APPENDIX 13.II.A.1 &
APPENDIX 13.II.B.1
APPENDIX 15.I.F.2
APPENDIX 15.I.F.2
APPENDIX 15.I.F.2
APPENDIX 15.I.F.2
APPENDIX 15.I.F.2
APPENDIX 15.I.F.4
APPENDIX 15.I.F.5
APPENDIX 15.I.F.6