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CLINICAL EXPERIENCE LOG - ORAL SURGERY, ORAL PATHOLOGY & ORAL MEDICINE
Patients Name : Registration Number :Supervisors name : Date patient first seen :Type of Cases : Date case completed :
*Please tick ()where applicable
*Please tick () where applicable1
Clinical Compeenc! Mana"emen
#O$%e'e (O) *A%%i% (A) *Con+c (C)
Dae Noe%(in $ie)
O A C
Patient clerking
istory: Present complaint !edical
Dental
"#amination: $eneral "#tra%oral &ntra%oral
Diagnosis ' treatment planDifferential
Definitive
Treatment plan
&npatient management
(dmission&nvestigation)s*
Non &nvasive
&nvasive
Radiograp+
&nformed consent
Treatment)s*
!edication)s*
Disc+arge' follo, up
Log-OSOMOP
Log-OSOMOP
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*Please tick () where applicable
-
Clinical Compeenc! Mana"emen
#O$%e'e (O) *A%%i% (A) *Con+c (C)
Dae Noe%(in $ie)
O A C
.utpatientmanagement
&nvestigation)s*
Non &nvasive
&nvasive
Treatment)s*
Prescription
/ollo, up
!anagement of medical 'dental emergencies
"mergency treatment
Referral
0asic life support
.n call cases
Pain ' an#iety control
Parenteral: &! &2 PC(
.ral medication: Sedation
(nalgesic
3ocal (nest+esia: &nfiltration Topical
(ssurance
.t+ers )specify*:
!inor oral surgery )Dento%alveolar surgery andot+ers*
"#odontia: Toot+Retained roots
Surgical Removal of: Retained root)s*&mpacted toot+
Toilet ' suturing
&ncision and drainage
&nfected dry socket
.t+ers
Log-OSOMOP
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Name of /4D. :55555555555555555555555
Supervisors signature : 55555555555555555555555
O.ERALL E.ALUATION O/ PER/ORMANCE
6
Clinical Compeenc! Mana"emen
#O$%e'e (O) *A%%i% (A) *Con+c (C)
Dae Noe%(in $ie)
O A C
!anagement of ma#illofacialtrauma
ard tissue in7uries
Soft tissue in7uries
!anagement of soft and +ardtissue pat+ology )if applicable*
ard tissue pat+ology
Soft tissue pat+ology
!anagement of oral oncology)optional*
Combine clinics
Surgical !anagement
Referral system follo, up re+abilitation
"arly detection andprevention of oral pre%cancer and oral cancer
.t+ers (please specify)
OE-OSOMOP
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A CLINICAL CASE PRESENTATION Ga+in"0elo1A'ea"e
A'ea"e
Goo+ O%an+in"
18 Skill in gat+ering clinical information )including emergency cases*
-8 Competence to diagnose ' /ormulate treatment plan
68 &mplementing treatment
0 COMMUNICATION S2ILL Ga+in"0elo1A'ea"e
A'ea"e Goo+ O%an+in"
18 "ffective doctor%patient communication skill
-8 Communicate effectively ,it+ ot+er professionals
68 (bility to address conflict
C PRO/ESSIONALISM Ga+in"0elo1A'ea"e
A'ea"e
Goo+ O%an+in"
18 &ntegrity 2alue
-8 (ccountability
68 Clinical competency
Overall comments (if any):
A) CLINICAL CA! P"!!N#A#ION
9
OE-OSOMOP
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$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
%) CO&&'NICA#ION
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
C) P"O!IONALI&
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
Supervisors signature : 55555555555555555555555
Name of Supervisor :55555555555555555555555
Date :55555555555555555555555
.fficial Stamp of Supervisor :
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CLINICAL EXPERIENCE LOG - PAEDIATRIC DENTISTRY
Patients Name : Registration Number :Supervisors name : Date patient first seen :Type of Cases : Date case completed :
*Please tick () where applicable
;
ClinicalCompeenc!
Mana"emen
#O$%e'e(O)* A%%i%
(A)*Con+c (C)
DaeNoe%
(in $ie)
O A C
Patient clerking
istory: Present complaint !edical
Dental
"#amination: $eneral "#tra%oral &ntra%oral
Diagnosis ' Treatment plan Differential Definitive
Treatment plan
&npatientmanagement
(dmission
&nvestigation)s*
&nformed consent
Treatment)s*
!edication)s*
Disc+arge
/ollo, up
Log-PaedDent
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*Please tick () where applicable
ue
!anagement of softand +ard tissue
in7uries
Toilet ' suturing
Splinting )if applicable*
Cro,n fracture
Root fracture )if applicable*
Displacement ' lu#ationin7uries
&ncision and drainageRemoval of teet+ under $(
"namel abnormalities
Dento alveolar fracture )ifapplicable*
Log-PaedDent
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Name of /4D. :55555555555555555555555
Supervisors signature :55555555555555555555555
Name' .fficial Stamp of Supervisor :55555555555555555555555 Date :
5555555555555555555
O.ERALL E.ALUATION O/ PER/ORMANCE
?
ClinicalCompeenc!
Mana"emen
#O$%e'e(O)* A%%i%
(A)*Con+c (C)
DaeNoe%
(in $ie)
O A C
!andibular fracture )ifapplicable*
!a#illary fracture )ifapplicable*
.t+ers: )Specify*
!anagement ofC+ildren ,it+ specialneeds
P+ysical impairment
"ducational impairment
!edically compromised
OE-PaedDent
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A CLINICAL CASE PRESENTATION Ga+in"0elo1A'ea"e
A'ea"e
Goo+ O%an+in"
18 Skill in gat+ering clinical information )including emergency cases*
-8 Competence to diagnose ' /ormulate treatment plan
68 &mplementing treatment
0 COMMUNICATION S2ILL Ga+in"0elo1A'ea"e
A'ea"e Goo+ O%an+in"
18 "ffective doctor%patient communication skill
-8 Communicate effectively ,it+ ot+er professionals
68 (bility to address conflict
C PRO/ESSIONALISM Ga+in"0elo1A'ea"e
A'ea"e
Goo+ O%an+in"
18 &ntegrity 2alue
-8 (ccountability
68 Clinical competency
1@
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Overall comments:
A) CLINICAL CA! P"!!N#A#ION
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
%) CO&&'NICA#ION
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
C) P"O!IONALI&
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
Supervisors signature : 55555555555555555555555
11
OE-PaedDent
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ClinicalCompeenc!
Mana"emen
#O$%e'e (O) *A%%i% (A) *Con+c (C) Dae
Noe%(in $ie)
O A C
"mergencymanagement
3oose bands Patients NameRegistration
No8Date seenType of case
::
::
3oose brackets
/ractured S+arp arc+,ires
0roken removableappliances
.t+ers )Specify*
&nterceptiveort+odontics ,it+removable appliance
Purpose of interception Patients NameRegistrationNo8Date seenType of case
::::
Type of appliance )Specify*
Design of appliance
&mpression taking for,orking model
&ssue of appliance andappropriate instructions
(ctivation of appliance
Revie, and monitoringprogress ).reinforcementA assessmentof patients compliance*
Relevant p+otos+ots
&nterceptive.rt+odontics ,it+functional appliance
Purpose of interception Patients NameRegistrationNo8Date seenType of case
::::
Type of appliance )Specify*
Design of appliance
&mpression taking for,orking model
&ssue of appliance andappropriate instructions
16
Log-ORTHO
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ClinicalCompeenc!
Mana"emen
#O$%e'e (O) *A%%i% (A) *Con+c (C) Dae
Noe%(in $ie)
O A C
(ctivation of appliance
Revie, and monitoringprogress ).reinforcement*
Relevant p+otos+ots
(ssessment of patientscompliance
/i#ed appliance
Placement of separators Patients NameRegistrationNo8Date seenType of case
::::
0anding and bonding
Tying in ,it+ ligatures orelastomeric modules
C+ange of arc+,ire andactivation
(nc+orage consideration)as necessary*
Revie, and monitoringprogress ).
reinforcement*.t+ers )Specify*
Debanding and debondingof fi#ed appliance
Stage p+oto s+ots
Cases of retention)Retainer*
Type of retainer )Specify* Patients NameRegistrationNo8Date seen
::::
Design of retainer
19
Log-ORTHO
*Please tick () where applicable
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ClinicalCompeenc!
Mana"emen
#O$%e'e (O) *A%%i% (A) *Con+c (C) Dae
Noe%(in $ie)
O A C
Type of case&mpression taking for,orking model
&ssue of retainer andappropriate instructions
Revie, and monitoringprogress ).reinforcement*
Stage p+oto s+ots
!ultidisciplinary cases).pportunistic*
Cleft lip and palate Patients NameRegistrationNo8Date seenType of case
::::
.rt+ognat+ic surgery
ypodontia cases
.t+ers )Specify*
Name of /4D. :55555555555555555555555
Supervisors signature :55555555555555555555555
Name' .fficial Stamp of Supervisor :55555555555555555555555 Date :
5555555555555555555
1
Log-ORTHO
*Please tick() where applicable
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O.ERALL E.ALUATION O/ PER/ORMANCE
A CLINICAL CASE PRESENTATION Ga+in"0elo1A'ea"e
A'ea"e
Goo+ O%an+in"
18 Skill in gat+ering clinical information )including emergency cases*
-8 Competence to diagnose ' /ormulate treatment plan
68 &mplementing treatment
0 COMMUNICATION S2ILL Ga+in"0elo1A'ea"e
A'ea"e Goo+ O%an+in"
18 "ffective doctor%patient communication skill
-8 Communicate effectively ,it+ ot+er professionals
68 (bility to address conflict
C PRO/ESSIONALISM Ga+in"0elo1A'ea"e
A'ea"e
Goo+ O%an+in"
18 &ntegrity 2alue
-8 (ccountability
68 Clinical competency
1;
OE-ORTHO
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Overall comments :
A CLINICAL CA! P"!!N#A#ION
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
% CO&&'NICA#ION
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
C P"O!IONALI&
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
Supervisors signature : 55555555555555555555555
1ue ,it+emp+asis on dentogingival
7unction
"#planation of alveolar boneloss ,it+ picture guide
1?
Log-PERIO
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/ull mout+ scaling
Subgingival debridement
Splinting
.cclusal ad7ustment
.t+ers )Specify*
*Please tick () where applicable
Clinical Compeenc! Mana"emen
#O$%e'e (O)* A%%i% (A) *Con+c (C)
DaeNoe%
(in $ie)O A C
Surgery
/lap surgery Patients Name:Registration No:Date seen:Type of case:
$ingivectomy
Root amputation rootresection
Cro,n lengt+ening
$uided tissue regeneration
$uided bone regeneration
&mplant
.t+ers )Specify*
Name of /4D. :55555555555555555555555
-@
Log-PERIO
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Supervisors signature :55555555555555555555555
Name' .fficial Stamp of Supervisor :55555555555555555555555 Date :
5555555555555555555
O.ERALL E.ALUATION O/ PER/ORMANCE
A CLINICAL CASE PRESENTATION Ga+in"0elo1A'ea"e
A'ea"e
Goo+ O%an+in"
18 Skill in gat+ering clinical information )including emergency cases*
-8 Competence to diagnose ' /ormulate treatment plan
68 &mplementing treatment
0 COMMUNICATION S2ILL Ga+in"0elo1A'ea"e
A'ea"e Goo+ O%an+in"
18 "ffective doctor%patient communication skill
-8 Communicate effectively ,it+ ot+er professionals
68 (bility to address conflict
-1
OE-PERIO
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C PRO/ESSIONALISM Ga+in"0elo1A'ea"e
A'ea"e
Goo+ O%an+in"
18 &ntegrity 2alue
-8 (ccountability
68 Clinical competency
Overall comments :
A) CLINICAL CA! P"!!N#A#ION
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
%) CO&&'NICA#ION
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
C) P"O!IONALI&
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$
--
OE-PERIO
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$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
Supervisors signature : 55555555555555555555555
Name of Supervisor :55555555555555555555555
Date :55555555555555555555555
.fficial Stamp of Supervisor :
CLINICAL EXPERIENCE LOG - RESTORATI.E DENTISTRY
Patients Name : Registration Number :Supervisors name : Date patient first seen :Type of Cases Procedures : Date case completed :
*Please tick () where applicable
Clinical Compeenc! Mana"emen#O$%e'e (O)* A%%i% (A) *Con+c (C)
Dae Noe%(in $ie)
O A C
Patient clerking
istory: Present complaint
Patients Name:Registration No8:Date seen:Type of case:
!edical
Dental
"#amination: $eneral
"#traoral
-6
Log -RESTO
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Clinical Compeenc! Mana"emen#O$%e'e (O)* A%%i% (A) *Con+c (C)
Dae Noe%(in $ie)
O A C
&ntraoral
.cclusal analysis
Clinical investigation)s*:B%ray"PT0ite test etc
Diagnosis Treatment plan
Patient management
&nformed consent Patients Name:Registration No8:Date seen:Type of case:
.ral +ygiene instruction education
.t+ers )Specify*:
Clinical Compeenc! Mana"emen
#O$%e'e (O)* A%%i% (A) *Con+c (C) Dae
Noe%(in $ie)
O A C
/i#ed prost+odontics .nlays Patients Name:Registration No8:Date seen:Type of case:
metal cro,n
/ull metal cro,n
Porcelain%fused to metalcro,n
&ndirect composite veneers
Porcelain veneer
(ll ceramic cro,n
/i#ed%fi#ed bridge
Cantilever bridge
-9
Log -RESTO
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Resin%retained bridge
Root canal treatment
(nteriors Patients Name:Registration No8:Date seen:Type of case:
Posteriors
Root canal retreatment
!anagement of comple#endodontic cases
"g: Curved rootsA PerforationASeparated instruments)Specify*:
Clinical Compeenc! Mana"emen
#O$%e'e (O)* A%%i% (A) *Con+c (C) Dae
Noe%(in $ie)
O A C
0leac+ing
0leac+ing
discolouredendodonticallytreated teet+
Patients Name:
Registration No8:Date seen:Type of case:"#ternal bleac+ing of
discoloured vital teet+
Removableprost+odontics orprost+etics )Comple#cases*
Sectional dentures Cobalt%c+rome partialdentures
Patients Name:Registration No8:Date seen:Type of case:Partial Dentures ,it+
precision attac+ment)eg: magnetic attac+ment*
Complete denture )Difficultcases*
.verdenture
-
*Please tick() where applicable Log -RESTO
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.t+ers"g: .bturatorsA .ro%ma#illofacial prost+eses )Specify*:
!anagement ofcomple# cases
!oderate to severe toot+,ear
Patients Name:Registration No8:Date seen:Type of case:
"#tensive root caries
Combination of fi#ed andremovable prostodontics
.t+ers )Specify*:
Name of /4D. :55555555555555555555555
Supervisors signature :55555555555555555555555
Name' .fficial Stamp of Supervisor :55555555555555555555555 Date :
555555555555555555588
O.ERALL E.ALUATION O/ PER/ORMANCE
A CLINICAL CASE PRESENTATION Ga+in"0elo1A'ea"e
A'ea"e
Goo+ O%an+in"
18 Skill in gat+ering clinical information )including emergency cases*
-8 Competence to diagnose ' /ormulate treatment plan
68 &mplementing treatment
0 COMMUNICATION S2ILL Ga+in"0elo1A'ea"e
A'ea"e Goo+ O%an+in"
18 "ffective doctor%patient communication skill
-;
OE -RESTO
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-8 Communicate effectively ,it+ ot+er professionals
68 (bility to address conflict
C PRO/ESSIONALISM Ga+in"0elo1A'ea"e
A'ea"e
Goo+ O%an+in"
18 &ntegrity 2alue
-8 (ccountability
68 Clinical competency
Overall comments :
A) CLINICAL CA! P"!!N#A#ION
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
%) CO&&'NICA#ION
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
C) P"O!IONALI&
-uire basic kno,ledge on t+e follo,ing topics t+roug+briefingA discussionsA presentationsA dialoguesA talksA etc
18 .ral ealt+care Services in !alaysia-8 NationalState .ral ealt+ Plan
68 .rganisation Structure98 Euality !anagement System)innovationA &S.A N&(A S( DS(A FP&A A!anagement of complaintsAClient C+arter*8 $eneral .rderA relevant circulars and oral +ealt+care
guidelines;8 &!S
(ttend briefing on /inancial !anagement18 /ee sc+edule : ProvisionsG procedures for e#emptionG
responsibility for daily collection-8 (ut+orityA control ' responsibility68 e%SPF0 e%perole+an98 Petty cas+8 Programme (greement;8 (udit
8/12/2019 Clinical Experience Log
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66
Compeenc! Aci'iie%Noe%
(Speci! +ae * place *po'i+e)
"t+ics ' legislative
To attend briefing on :
Dental (ct
Code of Professional Conduct
Private ealt+ Care /acilities (ct' Regulations
Communication 'leaders+ip
"ffective communication )personnel A patientsA carers family *
3eaders+ip >ualities
Log-CommOHC
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Supervisors signature :55555555555555555555555
Name' .fficial Stamp of Supervisor :55555555555555555555555 Date :
55555555555555555
O.ERALL E.ALUATION O/ PER/ORMANCE
A CLINICAL CASE PRESENTATION Ga+in"0elo1A'ea"e
A'ea"e
Goo+ O%an+in"
69
OE-CommOHC
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18 Skill in gat+ering clinical information )including emergency cases*
-8 Competence to diagnose ' /ormulate treatment plan
68 &mplementing treatment
0 COMMUNICATION S2ILL Ga+in"0elo1A'ea"e
A'ea"e Goo+ O%an+in"
18 "ffective doctor%patient communication skill
-8 Communicate effectively ,it+ ot+er professionals
68 (bility to address conflict
C PRO/ESSIONALISM Ga+in"0elo1A'ea"e
A'ea"e
Goo+ O%an+in"
18 &ntegrity 2alue
-8 (ccountability
68 Clinical competency
O.ERALL E.ALUATION O/ PER/ORMANCE
D MANAGEMENT AND LEADERSHIP Ga+in"0elo1A'ea"e
A'ea"e
Goo+ O%an+in"
6
OE-CommOHC
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18 Demonstrates effective leaders+ip ,it+in t+e +ealt+care teamA ,+ereappropriate
-8 &dentifies opportunities for >uality and safety improvementA anddevelopsA implementsand evaluates strategies to improve >uality ,+ere possible
68 Hnderstands t+e role of being mentor and role model for ot+ermembersof t+e +ealt+care team
98 (n understanding of t+e re>uirements for and processes involved inrisk assessment,it+in t+e ,orkplace and resultant action
8 Development of strategies ,it+ emp+asie on organiational visionAgoals and action plans
;8 Demonstrate an understanding of t+e financial management of ageneral dental practiceand ot+er relevant clinical environments
Overall comments:
(* C3&N&C(3 C(S" PR"S"NT(T&.N
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
6;
OE-CommOHC
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$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
0* C.!!HN&C(T&.N
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
C* PR./"SS&.N(3&S!
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$$$$$$$$$$
D* !(N($"!"NT (ND 3"(D"RS&P
55555555555555555555555555555555555555555555555555555
5555555555555555555555555
55555555555555555555555555555555555555555555555555555
5555555555555555555555555
Supervisors signature : 55555555555555555555555
Name of Supervisor :55555555555555555555555
Date :55555555555555555555555
.fficial Stamp of Supervisor :
6
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6=
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RE/LECTION /ORM
Name of /4D. : 5555555555555555588 Placement :555555555555555555
Supervisor Name : 5555555555555555588 Date :5555555555555555588
Please ive +escription on e cases enco,ntere+- competencies. +omains (clinical- lea+ership-
professionalism- comm,nication)* or activities reflecte+ ,pon Please con+,ct/self assessment on
what went well0 1hat +i+n2t o well0 1hat were the challenes0
6?
Reflection
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CASE-0ASED DISCUSSION ASSESSMENT /ORM(to be fille+ ,p by the ,pervisor)
Please ,se this format to write notes an+ recor+ the 3,estions yo, will ask +,rin or followin the casepresentation in or+er to assess the 4ental Officer2s clinical 5,+ement in this case:
Topic o pe%enaion4 55555555555555555555555588 Dae ope%enaion4 55555555
No Iem 0elo1A'ea"e
A'ea"e Goo+O%an+in
"
1
Content of Presentation:
a* &ntroduction
b* !et+od
c* Result
d* Discussion
e* Conclusion
-
Presenters skillful use of !SPo,erpoint or ot+er met+ods toen+ance t+e presentation
6
Presenters style of presentation and
t+e command of language used duringt+e presentation
9
Presenter +ave t+e appropriatekno,ledge and ability to ans,er t+e>uestion posed
* Case may refer to a particular patient / population / programme For clinical case presentation, the case history, relevant investigation and differential diagnosis should bediscuss and presented.
**This form is to be sent to state coordinator for compilation
9@
CBD
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CHEC2LIST O/ ASSESSMENTPlease tick (6) when the assessment is +one
Name of Dental .fficer :5555555555555555 !DC Number :
55555555555
Duration
(Month) Specialty Assessment Frequency Done ()
Ho%pial 0a%e+ Po%in"
5
Oal S"e!,
Oal Me+icine &
Oal Pa6olo"!
Lo"-OSOMOP
Min 5 ca%e% oOS
Min 7 ca%e% oOMOP
C0D Min 89
8 Pae+iaicDeni%!
Lo"-Pae+Den Min 7 ca%e%
C0D Min 89
Duration
(Month) Specialty Assessment Frequency Done ()
Non-Ho%pial 0a%e+ Po%in"
8 O6o+onic% Lo"-O6o
Min o :
paien%
8 Peio+onic%Lo"-Peio
Min o :
paien%
8 Re%oai'eLo"-Re%Den
Min o :
paien%
5
Pima!Heal6cae
Denal P$licHeal6 Pacice
Lo"-DPHMin ;
po"amme%
C$D Min 89
Relecion Min 89
Lo"-MP Min 89
IT+e rotation of specialist attac+ment s+all be determined at State level according to localre>uirements8