Care Plan Evaluation Form swaen Hale on Tur pate DANE ~ (4) Patient Name _ __- Instructor Grading Criteria: A score of 1 will be given if no significant errors are identified, A score of % will be given if 1-3 significant errors are identified. A score of 0 will be given if required information is missing of deemed inaccurate by the instructor. __ 1. Patient information is present. _| 2 Medical History findings are present. _|__ 3. Medical History risks are identified, _1 4. Social and Dental history risk factors are noted form Medical/Dental History _{_5. Social and Dental history risks are identified |_ 6, Dental Examinations findings (from ALL) from all paperwork are present. 7. Dental Examination risks are present | 8, Plaque score calculated correctly. 9. Bleeding score calculated correctly. 10. Periodontal case type assessed correctly. 11. Dental Hygiene diagnosis problems stated correctly. (List ALL problems, prioritize). | 12, Dental Hygiene diagnosis etiology stated 13. Planned intervention education stated clearly for each clinical finding 14, Planned intervention oral hygiene is appropriate for each clinical findings {__15.LTG 1 stated clearly. | 16. STG 3 goals stated appropriately for LTG 1 [17.112 stated clearly _ | 18, 1G 3 goals stated appropriately for LTG 2 er EET LE_}_ 19. L1G stated clearly. _|_ 20. STG 3 goals stated appropriately for LTG3. {__21. Prognosis is determined. _[ 22. Detailed description on how you determined prognosis. Yoo, Appointment - planned treatment. __| 24. Appointment plan education, counseling or OHI _| 45, referrals listed if necessary. __ (26. Recall interval. l 27. Turned in on time. ponts AUS = GRADE GE