Oral Care Clinical Evaluation Form

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Clinical Evaluation Form

To create your custom Clinical Evaluation Form, start by entering the following information:

Your Name:		Click here to print the full list of questions. Click here to print a sample of a finished form.
Facility Name:
Unit:
Sage Product #:
Return Form To:

Next, check the boxes next to the questions you would like to have printed on the form. A maximum of 10 questions can be selected. When finished, click "Next Step."

I understand my unit's oral cleansing and suctioning protocol.

The Q·Care® system makes it easier to follow my unit's oral care protocol.

Compared to previous interventions, the Q·Care® system makes it easier to comply with my unit's oral care protocol.

I understand routine oral cleansing and suctioning can help address three risk factors for healthcare-associated pneumonia (HAP).

I understand the importance of brushing teeth to remove dental plaque, a known risk factor for healthcare-associated pneumonia (HAP).

I understand the importance of maintaining the integrity of the closed in-line tracheal system.

The Q·Care® system's ease-of-use enabled me to provide more frequent oral cleansing.

The Q·Care® system's premixed cleansing solution saves time.

The Q·Care® system's comprehensive package is convenient to use, saves nursing time and promotes a standard approach to oral care.

The Covered Yankauer's retractable sheath helps protect itself from environmental debris [excludes Q·Care® Petite Yankauer (#6720) in #6704 kit].

The Suction Catheter effectively removes secretions from the oropharyngeal cavity.

Toothette® Oral Care Mouth Moisturizer effectively moisturized the lips and oral tissues.

By keeping oral care tools available at the point of use, the Q·Care® Bedside Bracket saves time and eliminates steps.

I recommend the Q·Care® Oral Cleansing and Suctioning System over previous interventions.

I understand my units oral cleansing and suctioning protocol.

The Q·Care® system makes it easier to follow my units oral care protocol.