Unit 4: Administrative Operations
Administrative Operations

Section 1. Policies and Procedures

Format and Topics

A uniform and standardized format should be used for all standing policies and procedures throughout the facility. A common format includes:

  • The purpose of the policy
  • The policy statement
  • A step-by-step description of the procedures required to implement the policy

All policies and procedures should be marked as either "new" or "revised" and should be signed and dated by the person whose authority it is to approve and implement them. Policies should be reviewed at least annually and revised as necessary.
A clinic policies and procedures manual commonly includes clinical care guidelines as well as operational and administrative policies and procedures. The lists and resources below are intended to be a guide for developing a new manual or reviewing an existing manual.

Detailed list of content areas, by topic:

Emergent dental infections
Opioid prescribing
Storing of medications in the clinic
Antibiotic premedication for the prevention of prosthetic joint infections
Hypertension screening and referral
Management of patients taking anticoagulants
Prevention and management of dental caries
Prescribing of dental radiographs
Intervals for routine dental exam and prophylaxis
Periodontal screening and therapy
Oral cancer screening
Biopsies and tissue specimen management
Dental equipment maintenance and repairs
Behavior management
Reporting of suspected child abuse

Organizational chart and lines of authority
Scope of services
Sliding fee eligibility and documentation
Fee schedule and sliding scale
Statement of clinic hours
After-hours care
Approved abbreviations
Policy for utilization of dental laboratories
QA and quality improvement (QI) plan
Access to emergent care
Broken appointments
Patient scheduling (multiple family members, multiple appointments, walk-in care)
Expected services by appointment type
Referral for medical or dental specialty care

Bloodborne-pathogens-exposure-control plan
Infection-control protocols, including needle capping, autoclave monitoring, handwashing, and surface disinfection

Language interpretation
Patient grievances
Release of information
Bill of rights and responsibilities
Handling of suspected child abuse cases

Procurement of supplies
Inventory system
Clinic security
Records management, documentation, and Medicaid compliance

Mercury safety
Radiation safety
Nitrous oxide safety
Response to medical device recalls
Emergency preparedness (fire and fire drills, medical emergencies, code blue)
Hazard communication and material safety data sheets

Pre-hire assessments
Interview structure
On-boarding processes and requirements
Position descriptions
Credentialing and privileging
Staff grievance procedures
Competency evaluation and standards of performance
Training and continuing dental education
Volunteer processes
Student processes