Part 4 Individual Surgeries This part to be photocopied for the appropriate number of surgeries in the practice Practice/clinic name: Surgery Number: Training Other (state Type of Surgery Dentist Hygienist surgery below) Information A. General Yes No Source 1 A Premises well maintained and clean with running hot water…………………. 2 A Room size and layout adequate for purpose (minimum of 9 square metres).. PSM Health and Safety 3 A Good lighting……………………………………………………………………..… 4 A Good ventilation………………………………………………………………..….. Information B. Suction Yes No Source 1 A Adequate venting of suction system:…………………………………..………… PSM Health and 2 I preferably exhaust air is vented outside the building or…… Safety 3 I mechanical ventilation (extract fan) in surgery……………… Information C. Unit/Chair Yes No Source 1 A Access in emergency……………………….…………………………………….. 2 A Unit free of risk to patients or staff………………..……………………………... PSM Health and Safety 3 A Adequate fixed equipment in good repair, including fully reclinable chair that is upholstered with water-resistant material with no tears or cracks..….. Information D. Cabinets/Work Surfaces Yes No Source Work surfaces are: 1 A clean, dry, uncluttered………………………………………..……………. SDCEP Decontamination 2 A smooth, impervious with sealed edges without gaps……………..……. into Practice guidance 3 A Satisfactory number and arrangement of 4 A Cabinetry adequate for 4-handed dentistry……………………………..………
Part 4 Individual Surgeries This part to be photocopied for the appropriate number of surgeries in the practice Practice/clinic name: Surgery Number: Type of Surgery Dentist Hygienist Training surgery Other (state below) A. General Yes No Information Source 1 A Premises well maintained and clean with running hot water…………………. PSM Health and Safety 2 A Room size and layout adequate for purpose (minimum of 9 square metres).. 3 A Good lighting……………………………………………………………………..… 4 A Good ventilation………………………………………………………………..….. B. Suction Yes No Information Source 1 A Adequate venting of suction system:…………………………………..………… PSM Health and Safety 2 I preferably exhaust air is vented outside the building or…… 3 I mechanical ventilation (extract fan) in surgery……………… C. Unit/Chair Yes No Information Source 1 A Access in emergency……………………….…………………………………….. PSM Health and Safety 2 A Unit free of risk to patients or staff………………..……………………………... 3 A Adequate fixed equipment in good repair, including fully reclinable chair that is upholstered with water-resistant material with no tears or cracks..….. D. Cabinets/Work Surfaces Yes No Information Source Work surfaces are: SDCEP Decontamination into Practice guidance 1 A clean, dry, uncluttered………………………………………..……………. 2 A smooth, impervious with sealed edges without gaps……………..……. 3 A Satisfactory number and arrangement of 4 A Cabinetry adequate for 4-handed dentistry……………………………..………
CPI-Checklist-v3-1.1.17-Part-4-Individual-Surgeries.docx