FFGDP(UK)
Practice Questionnaire
UPDATED – JULY 2008
Contents
Page Number
3
4
5-6
7-9
10-13
14-15
16-17
18
19
20-21
22-23
24
25
27
28-30
31
33
Section
Title
Candidate’s Details
Mentor’s Details
Guidance on Completing the Questionnaire
Practice Profile
The Structure
1
The Premises
2
Treatment Rooms
3
Radiography
4
Laboratory
5
Reception and Appointments
6
Staff and Staff Training
7
Infection Control
8
Waste Disposal
9
Medical Emergencies
The Process
10
The New Patient
11
Patient Communication and Treatment
Records
12
Prevention
The Outcome
13
The Outcome
34
35-36
Comments Page
Declarations
2
Candidate’s Details
First names
Surname
Please provide a passport photograph with your completed Practice Questionnaire
Qualification
Please list qualifications with
dates of when they were
awarded
Contact details
Name/number of house, street
Town
City
County
Postcode
Practice phone number
Home phone number
Mobile phone number
Email address
3
Date
Mentor’s details
First names
Surname
Contact details
Name/number of house, street
Town
City
County
Postcode
Practice phone number
Home phone number
Mobile phone number
E-mail address
4
Guidance on completing the Practice Questionnaire
Please read the Candidate’s Guide to the Fellowship in General Dental Practice and
the Regulations Relating to the Fellowship of the Faculty of General Dental Practice
(UK) prior to commencing work on your Fellowship submission.
1) It is suggested that the Practice Questionnaire be completed in several stages.
a) Work through the questionnaire assembling the evidence which will be presented in
your final portfolio of evidence. The aim of initial completion of the questionnaire is
to make the mentor’s visit as productive as possible and to enable you to get many
of the items organised at your convenience in advance of the visit.
b) Review the initial version of the Practice Questionnaire with your mentor and
discuss any queries during the mentor practice visit. The mentor will summarise any
queries or deficiencies in a written report to you, which may be an annotated copy
of your completed questionnaire.
c) Use the meeting with your mentor and the mentor’s report to amend any aspects of
your Practice Questionnaire and discuss with your mentor again.
d) Submit the final version of the Practice Questionnaire to the FGDP(UK) together
with the other evidence required for the Fellowship Assessment.
2) The Practice Questionnaire comprises a practice profile and 13 sections on different
topics. Each section is divided into a number of questions, the answers to which,
mostly ‘Yes’ or ‘No’, should be entered next to the question with a tick in the
relevant column.
3) Some questions will have either ‘C’ or ‘P’ marked next to them. In these cases you
should include either a Copy (C) or Photograph (P) to support your answer.
4) Where a copy is requested, this means a copy of a document/protocol/letter or
communication is required as evidence in support of your answer. The copy, or in a
few cases such as the practice brochure, an actual item should be clearly marked in
the top right hand corner with the number of the question. It should then be ordered
numerically and placed in a file, with each item in a separate clear plastic wallet. As
far as possible, the letters or clinical forms should be ones selected from actual
patient files and suitably anonymised.
5) Where a photograph is requested as evidence, these should be clearly marked in
the top right hand corner with the number of the question. They should also be
ordered numerically and placed in the file together with appropriate descriptions. It
is recommended that photographs are a minimum of 7”x 5” (18x13cm).
6) If you are unable to complete a question for any reason, or if a question is not
relevant to your practice, discuss this with your mentor and if necessary indicate this
with a bold line through the box(es).Make a note in the comments section at the end
of the questionnaire with a reference to the question number.
7) Many of the questions in the practice questionnaire are legal essentials for practice
and the rest are intended to provide a picture of your practice. The practice
questionnaire will be included as part of the portfolio of evidence, which will form the
basis of the final reflective discussion with two assessors at the College.
5
Please note
Some legal or statutory requirements may possibly change or be supplemented during
the period of the assessment or following updates to this questionnaire. You will be
expected to be aware of changes and may be asked to provide evidence that you have
complied with these.
If this questionnaire is completed more than one year before the date of the final
discussion meeting, then you will be asked to sign a confirmation that all the items
covered in it have been maintained in a current state.
6
Practice Profile
7
Practice Profile
Please complete the questions below with respect to the main practice in which you
work. Please see the declaration at the end of this document if you work in more than
one practice.
Full time
Part time
Full time
Part time
DCPs
Reception/Administration
1) How many dentists are
there?
2) How many hygienists are
there?
3) How many additional staff
are there?
4) How many dentist surgeries are there?
5) How many hygienist surgeries are
there?
6) Are there any dedicated surgeries e.g.
for oral surgery?
7) How many intra-oral x-ray machines are
there?
8) Is there an OPG machine?
9) Do you have cephalometric or
tomographic machines?
10) How many autoclaves are there?
11) How many ultrasonic baths are there?
12) Do you have a surgical dishwasher?
13a) Who is responsible for updating
compliance regulations, legal changes and
good practice?
13b) Is this person a dentist or practice
manager?
8
13c) How is the updating done?
13d) How do you ensure it is done
regularly?
13e) How do you ensure updated
information is passed to those concerned?
14) List journals taken and read
9
The Structure
This section covers the exterior and interior parts common to all
the dentists, and the services and facilities shared by all dentists
in the practice.
10
Section One - The Premises
No.
Question
1.1
Are the premises in good order, well maintained
and decorated?
Are there clear signs indicating the names and
qualifications of all the dentists who work at the
practice?
Is there good access for able-bodied adults and
children?
Are there adequate toilet facilities for the size of
practice?
Are the requirements of the Disability
Discrimination Act 1995 and 2004 understood and
complied with?
Are there adequate toilet facilities for disabled
persons?
Has a disabled access audit been carried out?
Has a practice risk assessment been carried out
both inside and outside and documented?
Is there an adequate waiting area with sufficient
seating, and a pleasant and relaxing ambience
suitable for the numbers of patients seen?
Is unhindered personal movement throughout the
practice possible, including access for a stretcher
in the event of a medical emergency?
Is there adequate parking for the number of
patients seen?
If there is not enough parking at the practice, does
the practice brochure indicate nearby parking and
street parking restrictions?
Does the practice brochure give details of public
transport services to get to the practice?
Is all surgery suction (central or individual)
externally vented?
Is amalgam separation installed?
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13
1.14
1.15
1.16
1.17
1.18
1.19
1.20
1.21
Yes
Is there a protocol for disinfection/filter replacement
in the suction system and are filters easily
accessible?
Do all surgeries and common facilities comply with
water board regulations as regards air gaps and
prevention of supply contamination?
If header tanks supply surgeries, do these have
well fitted lids?
Is air conditioning used in surgeries?
Is there a protocol for cleaning and disinfecting air
conditioning units?
Is there adequate ventilation in all areas?
11
No
Evidence
Required
P
P
C
C
P
P
C
C
1.22
If forced ventilation is used, is there a protocol for
cleaning units and for replacing filter pads if fitted
for air entering the surgery?
Are fire instructions clearly displayed in appropriate
places?
Is a fire alarm and smoke detection system fitted?
Are the alarm and detectors tested regularly
according to a protocol?
Is there a maintenance agreement for the alarm
systems?
Are the fire exits (other than normal access doors)
unlocked according to a protocol when the practice
is in use?
(Confirm in Comments section if necessary)
Is there a protocol for duties in the event of fire and
do all staff know what to do?
Are fire practices held regularly every six months
and documented?
Are an adequate number of suitable fire
extinguishers fitted at appropriate points?
C
1.31
Is there a service record for the fire extinguishers?
C
1.32
Are emergency fire exits and routes free of
obstructions?
If required, is there a fire safety certificate?
(Confirm in the Comments section if not).
Is the first aid kit suitable for the size of practice?
C
1.23
1.24
1.25
1.26
1.27
1.28
1.29
1.30
1.33
1.34
1.35
1.36
1.37
1.38
1.39
1.40
1.41
1.42
1.43
1.44
1.45
1.46
Is the first aid kit clearly marked?
Is there a sign showing where the first aid kit is
stored?
Is there a designated first aid person?
Is there a model store with an index system for
retrieval?
Is there a dedicated materials store?
Are materials that require refrigeration stored
correctly?
Are materials used in date sequence and staff
instructed in this?
Are batch numbers of drugs such as LA in use and
recorded?
Are all drugs stored in a locked cupboard with
records of expiry dates?
Is there a current test certificate for the
compressed air system?
Is there a written scheme of inspection for the
compressed air system?
Is there a current portable electrical appliance
schedule and record of testing, a regular visual
12
C&P
C
C
C
C
C
C
C
P
C
C
C
C
1.47
1.48
1.49
inspection of portable appliances and a periodic
testing of earthed appliances and fixed wiring?
Is a full Control of Substances Hazardous to Health
Regulations 2002 (COSHH) file maintained and
attention of staff drawn to changes/updates and a
record of this kept?
Is a health and safety law poster displayed or are
leaflets given to staff in their information pack?
Is a health and safety policy displayed or given to
staff?
1.50
Is the health and safety policy regularly updated?
1.51
Is an accident book that complies with the
Reporting of Injuries, Diseases and Dangerous
Occurrences Regulations (RIDDOR) 1995 and
Data Protection legislation maintained?
1.52
Is there a current certificate of notification under the
Data Protection Act 1998?
C
C
C
Have Data Protection requirements regarding
partners and associates been complied with?
1.53
1.54
1.55
1.56
1.57
1.58
Are Annual Practising Certificates of all dentists
and DCPs checked and filed? Enclose copy of
candidate's certificate and any DCPs candidate
works with.
Is defence organisation membership confirmed for
all dentists and DCPs?
(Enclose copy of candidate’s membership)
Is a performing rights certificate needed and if so
has this been obtained?
Is emergency lighting installed and tested?
C
If a laser is used, is this Class 3b or 4 and is it
registered with the local health authority, and a
laser protection adviser appointed?
Is there signage to indicate compliance with no
smoking legislation?
C
13
C
C
C
P
Section Two - Treatment Rooms
No.
Question
2.1
Do surgeries have adequate space for function of
equipment, seated operator and assistant, and
emergency access?
Are surgeries adequately screened from public
view?
Do hygienists have dedicated surgeries?
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13
2.14
2.15
Yes
Are there any dedicated surgeries for oral
surgery/implant placement/sedation etc.?
Are all surgery floors impervious to liquids and
sealed at the edges?
Where cleaning duties are divided between
cleaners and nurses, is this clearly defined?
Is equipment in good order with a maintenance
programme and a protocol for cleaning of
filters/spittoons/flushing water lines etc.?
Can the chair be laid flat or slightly head down in
an emergency?
Are all sterilised instruments stored on lidded,
sterilised or disposable trays or in closed bags or
pouches?
Are surgical instruments (forceps etc.) stored in
closed bags or pouches after sterilisation?
Are there an adequate number of instruments in
good condition to allow a proper sterilisation
routine sufficient for the number of patients etc.?
Is a lidded tray system used for instruments?
Are trays or kits prepared in advance for clinical
procedures in order to reduce handling and
repeated opening of storage drawers and
cupboards?
Are materials stored out of contaminated areas?
Are the following items single use and always
disposed of immediately after use?
 Saliva ejectors
 Matrix bands
 Endodontic files
 Needles and scalpel blades
 Impression trays
 Aspirator tips
 Air/water syringe tips
 Bibs for patients
 Towels for hand drying
 Cups for patients
 Endodontic files
14
No
Evidence
required
P
P
P
C
C
P
P
P
2.16
Is rubber dam equipment available?
2.17
Is rubber dam used routinely for endodontic
procedures?
2.18
2.22
Is rubber dam used for other procedures when
appropriate?
Are loupes used?
Is a timed curing light available with suitable test
equipment and a protocol and record of this?
Is a facebow available with access to a semiadjustable articulator?
Is electrosurgery available?
2.23
Is capsulated amalgam used?
2.24
Is the mixer enclosed and on a tray lined with
aluminium foil and with raised edges?
Is a mercury spillage kit available with instructions
for use?
Is waste amalgam stored under mercury
suppressant before disposal?
Are aspirating syringes used routinely?
2.19
2.20
2.21
2.25
2.26
2.27
15
C
C
Section Three - Radiography
No.
Question
3.1
3.3
Have the Health and Safety Executive been
informed of all radiographic equipment installed in
the practice?
Is there an intraoral machine available in each
surgery used by a dentist?
Are all machines 65Kv or over?
3.4
Are long cones used?
3.5
Is rectangular collimation used normally?
3.6
3.7
Are film holding/beam aiming devices used?
Is there an OPG machine?
3.8
If there is not an OPG machine in the practice, are
arrangements in place for radiographs to be taken
at a nearby location?
Is there a viewer for radiographs in each surgery?
3.9
Is digital radiography used?
(If this is used for all films, mark 3.10 and 3.11 as
No).
If developing is manual, are thermometers, timers,
temperature controls in place and used with a
protocol for times, cleaning and chemical change?
If developing is automatic, is there a protocol for
cleaning, chemical changes and use of the
machine?
Are radiographs taken and developed only by
appropriately trained and qualified staff?
Is there an ongoing audit of radiographic quality?
Is there a critical event protocol in the event of a
sudden deterioration in radiographic quality?
Are the fastest films compatible with diagnostic
quality used?
If you use digital radiography, do you have facilities
for film use and processing in the event of failure?
Is there a current test certificate for each machine?
Are all personnel taking and developing
radiographs trained in line with the requirements of
the Ionising Radiation (Medical Exposure)
Regulations 2000 and is this training documented?
Are local rules in place and displayed and
controlled areas defined including a malfunction
contingency plan?
16
3.2
3.10
3.11
3.12
3.13
3.14
3.15
3.16
3.17
3.18
3.19
Yes
No
Evidence
required
C
C
C
C
C
C
C
3.20
Has a Radiation Supervisor been appointed?
3.21
Has a Radiation Protection Adviser been
appointed?
3.22
Is there a radiation protection file?
3.23
Is there a quality assurance programme for
radiographs?
Are personal film badges worn, if necessary, and
recorded?
Is there a warning signal to denote that
radiographic equipment is in use?
Has the candidate attended a radiology course
within the previous five years?
3.24
3.25
3.26
17
C
Section Four - Laboratory
No.
Question
4.1
Are all laboratories used registered with the
Medical Devices Agency?
Are there arrangements for casting unstable
impressions rapidly?
Is there a disinfection protocol for impressions
going to the laboratory and work coming from the
laboratory including preparation and use of the
solution?
4.2
4.3
Yes
4.4
Are all impressions and work returned from the
laboratory disinfected according to this protocol?
4.5
Are all disinfected impressions clearly marked as
disinfected?
4.6
Have disinfection procedures been discussed and
agreed with the laboratory?
4.7
Is disinfection recorded on standard laboratory
sheets?
Are clear instructions given for all laboratory work
and copies filed in the patient notes?
Is there a system for quality checking work
received from the laboratory before fitting?
4.8
4.9
4.10
Is there a system for ensuring all lab work is back
in good time before the patient’s appointment?
4.11
If there are facilities in the practice for
polishing/adjusting work, are there adequate dust
collection/cross infection systems?
Does the laboratory use magnification for
appropriate stages of work eg trimming dies etc.?
4.12
18
No
Evidence
required
C
C
(lab sheet)
Section Five - Reception and Appointments
No.
Question
5.1
Is there an appointment protocol for appointment
lengths/urgency etc.?
Is there a protocol for emergency patients?
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
Yes
Is there a rota to ensure out of hours care?
Is there an answer phone giving out of hours
contact phone numbers?
Are out of hours calls followed up and entered in
patients' notes even if the patients were not seen?
Is a log of calls for dentists kept and the response
documented?
Are adequate arrangements made for care of
patients during holiday times?
Is there an adequate number of phone lines for the
number of reception staff/dentists etc.?
Is there an internal communication system?
Is there privacy for patients making
appointments/discussing private matters and for
staff taking phone calls etc.?
19
No
Evidence
required
C
C
C
P
Section Six - Staff and Staff Training
No.
Question
6.1
Are all personal records kept in a locked file, or if
on computer, in a section with password
protection?
Do all staff have a contract of employment which
complies with current legislation and meets the
guidance in Current Guidance Section 12?
Do all staff have a job description?
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.15
6.16
6.17
6.18
6.19
6.20
6.21
6.22
6.23
Do all contracts include a confidentiality clause?
Do all new staff receive an introductory package
which includes all health and safety matters and
practice protocols relevant to their jobs?
Is there an additional induction process for young
staff under The Health and Safety (Young Persons)
Regulations 1998?
Do all new staff undergo a period of induction
training?
Are all clinical staff vaccinated against hepatitis B
and records kept of seroconversion and booster
dates?
Are all staff vaccinated against:
Diptheria?
Pertusis?
Poliomyelitis?
Rubella?
Tuberculosis?
Tetanus?
Are records kept of vaccination dates and booster
dates?
Is there a protocol for needlestick injuries with an
up to date contact phone number for occupational
health advice and referral?
Are all staff issued with an adequate number of
protective surgery uniforms?
Do all clinical personnel wear surgery uniforms
only in the practice and change clothing when
travelling to and from work?
Are surgery uniforms changed daily and washed at
a temperature of 65°C?
Is there a staff rest room of adequate size?
Are there private changing areas and storage for
outside clothing?
Are all DCPs enrolled or registered as appropriate
with the GDC for CPD?
Is there a documented continuing training scheme
20
Yes
No
Evidence
required
C
C
C
C
6.24
6.25
6.26
6.27
6.28
6.29
6.30
6.31
6.32
6.33
for dental nurses and, in the event of a change of
duties, is training given and recorded?
Are all dental nurses at the practice registered with
the GDC or on approved training courses?*
Are all technicians in the laboratories you use
registered with the GDC?**
Do all dentists in the practice maintain CPD and
have a personal development plan?
Do all staff receive a documented annual
appraisal?
Are there regular staff meetings with minutes?
Are the Health and Safety (Display Screen
Equipment) Regulations 1992 complied with and
staff offered relevant eye checks?
Is health and safety training updated e.g. hazard
assessment and COSSH as part of continuing
dental nurse training?
Does the practice have an equal opportunities
policy?
Does the practice have a disability policy?
Is there a grievance and disciplinary policy?
C
C
C
C
C
C
* Evidence for this would be required in the form of a copy of a nurse’s current GDC registration
document or a letter confirming a nurse's place on a training course. This evidence should relate to the
nurse with whom the dentist works.
** Evidence for this would be copies of GDC registration documents or a letter from the lab confirming
their technicians are registered.
21
Section Seven - Infection Control
No.
Question
7.1
Does the practice have a written infection control
policy that is regularly updated and given to all
clinical staff?
Is responsibility for ensuring day to day compliance
with the protocol defined e.g. the dentist or the
practice manager?
Is there an autoclave in each surgery or is there
one available easily for each surgery?
Do the infection control protocols include;
7.2
7.3
7.4
Yes
1. Pre-sterilisation and sterilisation procedures
 Use of timed ultrasonic baths and/or washer
disinfectors for pre-cleaning and a protocol for
changing liquids/maintenance etc.?
 Cleaning, lubrication and sterilisation of
handpieces?
2. Aseptic storage
 Sterilised instruments for all invasive
procedures are stored in sealed containers or
pouches?
3. Personal disinfection procedures and
protective equipment
 Use of heavy gloves and long handled brushes
for scrubbing soiled instruments before
sterilisation?
 New gloves and masks for each patient?
 Protective glasses for patient and clinical
operators?
 Handwashing and skin care?
 Transport of contaminated waste to the store
for collection?
(Enclose a copy of the detailed protocols)
4. Infection control procedures
 Surgery zoning and work surface cleaning?
 Covering of computer keyboards in clinical
areas?
5. Single use items to be used when possible,
including the following:
 Use of disposable needles?
 Use of disposable mouthrinse beakers,
aspirator tips, 3 in1 tips, impression trays?
22
No
Evidence
required
C
P
C




7.5
7.6
7.7
7.8
7.9
7.10
7.11
7.12
7.13
7.14
7.15
7.16
7.17
7.18
Disposable bibs, covers for light handles, unit
controls, instrument and suction tubes and
cables (or cleaning of smooth surfaced tubes),
headrests and chair controls if not foot
controlled?
Appropriate disposal into containers for sharps,
used LA cartridges, and clinical waste?
All instruments marked with the single-use logo
discarded after one use?
Endodontic instruments are disposed of after
one use?
Are nitrile or other latex-free gloves available in
case of allergies?
Are sterile gloves available for surgical use?
Are all units fitted with anti-retraction valves?
Do units use bottled water?
Is a dental unit water supply disinfectant used for
water supply bottles and to clear the unit of biofilm
with a protocol for retreatment?
Are all autoclaves under a maintenance contract
and do all have a current test certificate?
Are instruments stored in covered trays or bagged
after autoclaving?
Is the autoclave tank emptied every night?
Is purified water used for the autoclave?
Is there a vacuum autoclave with a current test
certificate, maintenance contract and a protocol for
use/bagging as well as adequate provision of
appropriate bags?
Are appropriate daily tests for autoclaves
recorded?
Is a chlorhexidine preoperative mouthwash used:
Always?
Prior to surgery/use of ultrasonic scalers?
Are the same infection control protocols used for all
patients?
Do you have arrangements for the treatment of
CJD sufferers or high-risk patients?
23
C
C
C
C
Section Eight - Waste Disposal
No.
Question
8.1
Is there a protocol for separation and storage of
confidential office waste/clinical waste/special
waste/non-hazardous and hazardous waste and
sharps?
Is there safe secure labelled storage with no public
access for:
 Used sharps bins?
 Clinical waste?
 Special waste (used LA/drug vials)?
 Mercury/amalgam?
 Radiographic chemicals?
 Lead foil?
 Office waste?
Are contracts in place for the proper disposal of the
above to authorised contractors?
Are records kept of the disposal of waste as
required?
8.2
8.3
8.4
Yes
24
No
Evidence
required
C
C
C
Section Nine - Medical Emergencies
No.
Question
9.1
Are all staff aware of the protocol to alert members
of the practice in the event of a medical
emergency?
Is there a written protocol concerning patients who
collapse, which includes calling for paramedic
assistance and provides details of staff duties in
collecting drugs, oxygen, suction and also gives
details of where the items are kept? Are all staff
aware of this protocol and is this practiced and
recorded? Is this protocol in the practice handbook
(if there is one) and is it included in the induction of
new staff?
Are CPR sessions held at least annually and
attendance documented? Are steps taken to
ensure that all staff are included in this training
(particularly part time staff)?
Is portable pressure oxygen available?
9.2
9.3
9.4
Yes
9.5
Is there a protocol and record of testing of oxygen
contents?
9.6
Is there a ‘Laerdal’ face mask or equivalent in each
surgery?
9.7
Is there a positive pressure ventilation device?
9.8
Is there a spare oxygen cylinder?
9.9
Are there adequate sizes of airways and
facemasks?
Is there a recommended stock of emergency
drugs, needles, syringes etc in a portable pack?
(e.g. BNF or local equivalent)*. (* The reason for
this is that there are different legislation in Scotland
from England and Wales and guidance in Scotland
that differs from BNF).
9.10
9.11
Are all dentists trained to administer the
appropriate drugs in an emergency?
9.12
Is there a system to replace out of date drugs
before they expire?
Is portable suction available independent of the
central suction?
Is the use of drugs by those qualified to use them
reviewed regularly and documented?
Do all staff know how to lay all chairs flat?
9.13
9.14
9.15
25
No
Evidence
required
C
C
C
C
C
C (list)
C
THE PROCESS
This section covers communication with the patient before and
during a course of treatment and the recording of this process.
The provision of a rational maintenance programme at the
conclusion of the treatment is also covered.
26
Section Ten - The New Patient
No.
Question
10.1
10.2
Is there a practice brochure?
Does the brochure give the names, qualifications
and dates obtained, of all dentists, hygienists and
therapists in the practice?
Does the brochure give details of specialist listing,
visiting specialists and special interests?
Does the brochure give details of the facilities of
the practice including disabled access?
Does the brochure give normal opening hours,
phone numbers and out of hours contact
arrangements?
Are details of treatment arrangements eg.
private/NHS/insurance detailed in the brochure?
Is a welcome letter sent to confirm the first
appointment and any fees for this if not contained
in the brochure?
Is a general health questionnaire sent to new
patients or given to them on arrival?
10.3
10.4
10.5
10.6
10.7
10.8
Yes
27
No
Evidence
required
C
C
C
Section Eleven - Patient Communication and Treatment
Records
No.
Question
11.1
Is there a standard treatment record card or
computer field that records contact details, historic
treatment and general health information together
with current findings?
Is there an easily visible warning of a medical
health risk?
Is there an easily updated general health
questionnaire?
Are records stored securely without public
access?
If a computer system is used, is this password
protected?
Is a daily backup taken and stored remotely?
Is the system protected against disc failure by
duplicate recording etc.?
If the practice has internet access, is the system
firewall protected?
Are clear legible records kept of all treatment and
advice, including out of hours advice?
If computer records are used, is the system
protected against alteration, with an adequate
audit trail for mistakes rectified later?
Is a soft tissue examination carried out and
recorded for action/review of findings?
Is a basic periodontal examination carried out as
in the Guidelines of the British Society of
Periodontology?
Are written hygienist prescriptions given?
Are patients with significant periodontal disease
reviewed after hygienist treatment for further
treatment/review?
Do records show an assessment of caries/
periodontal/toothwear/oral pathology risk levels?
Are radiographs labelled, mounted for comparison
of serial (eg. bitewing/endodontic) films and
stored for easy retrieval?
Is the use of radiographs justified, reported on
and recorded?
How are patients recalled for any pathology found
on radiographs?
Do records show details of a preventive strategy
agreed with the patient?
Do records show a maintenance plan for
dentist/hygienist recall intervals based on risk?
Are treatment options recorded and written
treatment plans given with an estimate of the fees
28
11.2
11.3
11.4
11.5
11.6
11.7
11.8
11.9
11.10
11.11
11.12
11.13
11.14
11.15
11.16
11.17
11.18
11.19
11.20
11.21
Yes
No
Evidence
required
C
C
C
C
11.30
and payment details?
Are changes in treatment plans agreed with the
patient and the details recorded?
Are reminder letters sent, or are appointments
booked at the conclusion of treatment for recall?
Is there a proforma for referral letters to ensure
full details/history etc. are recorded and that
patients are followed up?
If you receive referrals is there a protocol for
making arrangements/filing correspondence and
managing the patient?
If you send pathological specimens by post, is
there a protocol to comply with postal regulations/
record of date sent/follow up with the patient?
Do you provide inhalation/oral/intravenous
sedation?
If no, then strike out 11.28 to11.40
Do you have a certificate of training in sedation?
Do you have a trained and certified dental nurse
or second appropriate person present?
Do you have a pulse oximeter?
11.31
Do you have a sphygmomanometer?
11.32
Do you have a stethoscope?
11.33
Do you have an adequate supply of drugs,
reversal agents and resuscitation equipment?
If you provide Relative Analgesia, do you have a
suitable machine with a service contract?
Do you have an adequate supply of scavenging
nosepieces for this?
11.22
11.23
11.24
11.25
11.26
11.27
11.28
11.29
11.34
11.35
11.36
11.37
11.38
11.39
11.40
11.41
11.42
11.43
Does the room used for Relative Analgesia have
adequate ventilation?
Do you have a consent form for sedation
techniques?
Do you have a leaflet or letter which explains
sedation/pre-treatment diet and the need for
accompanying persons?
Do you discharge only to an accompanying
person?
Are all drugs/dosages/reactions recorded in the
notes?
Is the practice registered under the Freedom of
Information Act and is the appropriate statement
completed?
Do you use post-treatment leaflets after
extractions/surgery or other treatment containing
contact instructions in the event of problems?
Please submit copies of five patient record cards
which demonstrate current record keeping
methods and standards. Your mentor will view a
29
C
C
C
C (list)
C
C
C
C
larger number with you and offer guidance on
selection of an appropriate and representative
sample for submission to the assessors.
30
Section Twelve - Prevention
No.
Question
12.1
What is the fluoride concentration in the water
supply to areas served by the practice? Please
state level of PPM in the evidence box
12.2
12.3
Does the practice have preventive leaflets?
Does the practice use diet sheets?
12.4
Does the practice sell or recommend a supplier of
preventive/oral hygiene aids?
Is there a “high caries protocol” for use in the
practice?
Are patients assessed for caries risk and is this
recorded?
Are patients assessed for periodontal disease risk
and is this recorded?
Is there a smoking cessation programme with
contact to specialist centres for this?
12.5
12.6
12.7
12.8
Yes
31
No
Evidence
required
C
C
C
The Outcome
In the context of this document we are concerned only with the
methods of assessing outcomes in the practice rather than with
a detailed evaluation of the outcome of clinical procedures.
32
Section Thirteen - The Outcome
No.
Question
13.1
Do you carry out patient opinion surveys? Please
provide evidence of a recent survey carried out
within the last 2 years and discuss any changes
you may have made as a result of this.
13.2
Yes
Evidence should be submitted in the form of the
survey summary detailing the following:
 Aim of the survey
 Areas of questioning and size of the sample
 Summary of results
 Action taken
 Result of action taken on practice
Do you have a complaints protocol and
procedure?
33
No
Evidence
required
C
C
Comments Page
Please state the number of the question alongside any comments which you may wish
to make about specific questions. Please duplicate this page if necessary.
Candidate’s Comments
Mentor’s Comments
Candidate’s signature: __________________________
Mentor’s signature: ____________________________
Date: _________________________
34
Declarations
Candidate Declaration
To be completed by the candidate
I ________________________________ submit this Practice Questionnaire as part of
the evidence for the Fellowship by Assessment.
Signed: _____________________
Date of completion of the questionnaire: ___________________
With the completed Practice Questionnaire you should include a passport photograph.
Please ask your mentor to sign and date the back of the photograph, including the
following wording: ‘I certify that this is a true likeness of…………’
Mentor’s Declaration and Validation of Evidence
To be completed by the mentor
I, __________________________________ FFGDP(UK), am acting as Mentor for
_____________________________________ at (practice address)
____________________________________. I have compiled written reports and given
additional advice to the candidate, as necessary. As part of the candidate's preparation
for the Fellowship Assessment and validation of evidence submitted by the candidate, I
have reviewed the following:
1. Emergency Resuscitation equipment and drugs to ensure compliance with current
regulations and Faculty guidelines.
2. Practice staff manuals including induction protocols for new staff to ensure
compliance with Faculty guidelines
3. Areas of the practice covered by photographic evidence to ensure the photographs
are a true representation of the candidate's practice.
4. A selection of clinical records to ensure record-keeping complies with the Faculty's
Clinical Examination and Record-Keeping: Good Practice Guidelines.
5. Patient records submitted as evidence by the candidate to ensure these are
representative of the general quality of record keeping.
6. The completed questionnaire and accompanying evidence to ensure it is a true
reflection of the candidate and their practice
7. If clinical cases are to be discussed, the patients were seen to confirm the evidence
submitted to the assessors is a true reflection of the clinical state of the patient(s).
If further visit(s) were made by the mentor, please indicate below the date of the last
visit and the outcome of this visit.
Outcome of visit:_____________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
35
VALIDATION
I confirm that all the evidence submitted is a true reflection of the Candidate, their
practice and their patient care.
Signed: _______________________ Date: ________________
To be completed by the candidate if necessary
Candidate’s declaration if practising at more than one site:
I, ______________________________________ understand that as the FFGDP(UK)
is a personal qualification I am expected to maintain the same standards in all places in
which I practice and confirm that this is so.
Signed: ________________________ Date: __________
36