Compliance with Professional
Standards Questionnaire
Contact Details
Name:
Registration No:
Telephone:
Email:
Infection Control
Please circle “Yes” or ‘No” and attach an explanation for all negative responses
1. Vaccination of clinical staff current (signature required if
declined)
2. Protocol for infection control available and staff trained
3. Personal Protective Equipment:
 gloves worn (single use)
 protective clothing/equipment worn in clinical area only
 suitable protective eyewear available
4. Items in contact with blood, saliva, and mucous membranes
either disposed of or sterilised between patients
5. Autoclave used for sterilisation and validated
6. Appropriate decontamination prior to disinfection or
sterilisation procedures
7. Handling and disposal of sharps and waste appropriate
8. Storage of instruments appropriate
9. Appropriate procedures in place for cleaning and disinfection
of environmental surfaces between patients and materials
labelled
10. No food or drink in clinical and sterilising areas
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Emergencies
Please circle “Yes” or ‘No” and attach an explanation for all negative responses
1. Dentist has completed training to a level equivalent to the
NZRC Modular Certificate of Resuscitation and Emergency
Care (CORE) Level 4 in the last 4 years
2. Staff trained in emergency procedures including CPR
3. Manual for dealing with emergencies immediately available
including essential telephone numbers
4. Patient medical histories up to date
5. Appropriate emergency drug kit and equipment up to date,
operational, and readily available
6. After an emergency, the patient never leaves
unaccompanied
12/02/16
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Records
Please circle “Yes” or ‘No” and attach an explanation for all negative responses
1.
2.
3.
4.
5.
Legible and time bound for all patients
Privacy and confidentiality provisions in place
Storage of records adequate
Patient access provisions in place
Basic information up to date:
 name, date of birth, gender
 address
 if under 18 contact details of parent or guardian
 current medical history
6. Records contain details, as appropriate, of:
 all visits, failures and cancellations
 presenting complaint
 history
 clinical findings
 diagnosis
 options and treatment plan
 treatment carried out
 treatment patient unwilling to proceed with
 consent obtained
 fee estimates given
 unusual sequelae
Yes
Yes
Yes
Yes
/
/
/
/
No
No
No
No
Yes
Yes
Yes
Yes
/
/
/
/
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
/
/
/
/
/
/
/
/
/
/
/
No
No
No
No
No
No
No
No
No
No
No
Sedation (if providing sedation)
Please circle “Yes” or ‘No” and attach an explanation for all negative responses
1.
2.
3.
4.
5.
6.
7.
8.
Appropriate level of conscious sedation training
Appropriate level of emergency training current
Patient medical histories up-to-date and relevant
Pre and post operative instructions given
Informed consent detailed in records
Records detail drugs, dosage, and timing
Equipment appropriate, available, and maintained
Facilities adequate (including for recovery
when necessary)
9. Appropriate trained staff always present during
procedure
10. Appropriate emergency drugs available
11. Discharge protocol in place
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Informed Consent
Please circle “Yes” or ‘No” and attach an explanation for all negative responses
1. Systems in place for oral and written consent
2. Systems in place for language /communication difficulties
3. Records include:
 treatment options including possible consequences
 estimated costs of options
 consent noted
 consent in writing where appropriate
 consent from caregiver where appropriate
 treatment refused and consequences of the decision
 option for referral if appropriate
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
2
Working relationship with dental hygienists and dental auxiliaries (where relevant)
Please circle “Yes” or ‘No” and attach an explanation for all negative responses
1. A signed professional agreement is in place with the hygienist(s)
/dental auxiliary in relation to the provision of clinical guidance,
direct supervision, radiography and access to prescription
medicines as required by the scope of practice for a hygienist
or dental auxiliary
Yes / No
2. The dentist examines all new patients, assesses the medical
history and develops the oral health care plan
Yes / No
3. The dentist provides timely advice and ensures the hygienist
has access to advice and guidance when off site
Yes / No
4. The dentist assesses the medical history of patients who
self-refer to the hygienist
Yes / No
5. The dentist is onsite when dental hygiene services are
provided to patients who self-refer to the hygienist or have
been referred by other dentists
Yes / No
6. Dental hygienists registered to provide LA do so only when
the dentist is on the premises (direct supervision)
Yes / No
7. Dental hygienists only treat patients under sedation in
accordance with the Code of Practice on Conscious
Sedation
Yes / No
8. All activities performed by dental auxiliaries are under the
direct clinical supervision of the dentist who remains onsite
Yes / No
9. The dentist ensures that the specific requirements in relation
to dental hygienists and auxiliaries registered in the additional
radiography and orthodontic procedures scopes are met
Yes / No
Professional relationships associated with the practice of dental therapy (where
relevant)
Please circle “Yes” or ‘No” and attach an explanation for all negative responses
1. A signed professional agreement is in place with the therapist(s)
in relation to the provision of advice, radiography and access
to prescription medicines
Yes / No
2. The dentist provides advice on the same working day as it
is sought
Yes / No
3. The dentist ensures access to timely advice in the event of
his or her unavailability
Yes / No
4. The dentist keeps accurate records of advice given
Yes / No
5. The dentist ensures that the specific requirements in relation
to dental therapists registered in the additional radiography
and adult scopes are met
Yes / No
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Professional relationships associated with the practice of dental technology and
clinical dental technology (where relevant)
Please circle “Yes” or ‘No” and attach an explanation for all negative responses
1. Patients are informed of all treatment options available
2. Timely advice is provided to the technician undertaking the
dentist’s work on request
3. Dental technology services are sourced from registered
practitioners
4. Overseas dental technology services are sourced from ISO
accredited laboratories
5. Oral health certificates are only provided when there is no
diseased or unhealed hard or soft tissues or any other
contraindicating abnormalities
6. Accurate records are kept on advice given, prescriptions
provided and oral health certificates issued
7. The dentist retains responsibility for the preparation of teeth
and/or soft tissues for partial dentures, immediate dentures
and overdentures and for the fitting and clinical care
outcomes of immediate dentures and root or implant
supported overdentures
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Declaration
I hereby declare that:
 the information I have given in this questionnaire is true and correct
 I understand that I may be visited to confirm the accuracy of the responses given in this
questionnaire
 I have attached an explanation for all negative responses and a timeframe for ensuring
compliance
Name:
Registration Number:
Signed:
Date:
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