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Clinical Experience Log

Jun 03, 2018

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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

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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

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    $$$$$$$$$$$$$$$$$$$$$$$$$

    6;

    OE-CommOHC

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    $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

    $$$$$$$$$$$$$$$$$$$$$$$$$

    0* C.!!HN&C(T&.N

    $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

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    $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

    $$$$$$$$$$$$$$$$$$$$$$$$$

    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