Checklist template

Dental radiography and nitrous oxide safety

A ready-to-use checklist with 117 items in 6 sections, covering Radiography equipment, Shielding and dosimetry, Nitrous system, Scavenging, Training, Records. Use it as-is in Bindy, or adapt it to your own standards in minutes.

  • 6 Sections
  • 117 Items
  • 94 Yes / No checks
  • 6 Scored ratings
  • 124 Points

Use this template How audits work

1. Radiography equipment 20 items

  1. Intraoral x-ray units at the practice Number
  2. Panoramic and cone beam units at the practice Number
  3. The latest report of a qualified inspector on the x-ray units is within the interval required by local regulation Yes / No 1 pt
  4. Deficiencies listed in the last inspection report have been corrected, with the repair record on file Yes / No 1 pt
  5. Rectangular collimators are fitted to the intraoral units Yes / No 1 pt
  6. Position-indicating devices are open-ended and free of cracks Yes / No 1 pt
  7. The exposure switch lets the operator stand behind a barrier or at least 6 ft (2 m) from the tube head, out of the beam Yes / No 1 pt
  8. Exposure stops as soon as the exposure switch is released Yes / No 1 pt
  9. A technique chart with adult and child settings is posted at each control panel Yes / No 1 pt
  10. The audible and visible exposure indicators work on each unit Yes / No 1 pt
  11. Intraoral images are taken with digital sensors, phosphor plates or the fastest film speed available Yes / No 1 pt
  12. The setting selected for each exposure observed matched the technique chart Yes / No 1 pt
  13. Sensor holders are used so that neither the patient nor an employee holds the sensor with fingers Yes / No 1 pt
  14. Handheld x-ray units are stored in a locked cabinet when not in use Yes / No 1 pt
  15. The backscatter shield is in place on each handheld x-ray unit Yes / No 1 pt
  16. The emergency stop on the panoramic or cone beam unit works Yes / No 1 pt
  17. Cone beam scans use the smallest field of view that covers the area ordered by the dentist Yes / No 1 pt
  18. X-ray units are switched off at the control panel at the end of the day Yes / No 1 pt
  19. A radiation warning sign is posted where required by local regulation Yes / No 1 pt
  20. Condition of the radiography equipment Rating
    • All units in good working order 5 pts
    • Minor defects not affecting safety 3 pts
    • Defects affecting safety or image quality 1 pt

2. Shielding and dosimetry 23 items

  1. A shielding assessment is on file for each room where x-ray units are installed Yes / No 1 pt
  2. The layout of each x-ray room is unchanged since its shielding assessment Yes / No 1 pt
  3. The operator can see and speak to the patient from the protected position during the exposure Yes / No 1 pt
  4. Only the patient was in the room during the exposures observed Yes / No 1 pt
  5. Patient lead aprons and thyroid collars are available where local regulation or company policy calls for them Yes / No 1 pt
  6. Lead aprons are hung on hangers or rails, not folded Yes / No 1 pt
  7. Lead aprons and thyroid collars are free of visible tears and cracks Yes / No 1 pt
  8. Lead aprons and thyroid collars were checked for damage in the last 12 months, with the check recorded Yes / No 1 pt
  9. Date of the last lead apron check Date
  10. Dosimeter badges are issued to the employees named in the radiation protection program Yes / No 1 pt
  11. Employees observed wore their dosimeter badge at collar or chest level Yes / No 1 pt
  12. Badges not being worn are kept on a rack outside the x-ray rooms, together with the control badge Yes / No 1 pt
  13. Badges are exchanged on the schedule set by the dosimetry service Yes / No 1 pt
  14. Dosimetry reports are initialed by the radiation safety officer Yes / No 1 pt
  15. Highest individual badge reading in the last period (mSv or mrem) Number
  16. Each badge reading above the investigation level of the program has a written investigation on file Yes / No 1 pt
  17. Employees who declare a pregnancy are offered the monitoring and duty changes set out in the program Yes / No 1 pt
  18. Patients of childbearing age are asked about pregnancy before radiographs, as company policy requires Yes / No 1 pt
  19. A parent or caregiver who must hold a patient is given a lead apron Yes / No 1 pt
  20. Radiographs are taken only on a dentist's order following an examination, not on a fixed timetable Yes / No 1 pt
  21. Retakes are recorded in a log with the reason Yes / No 1 pt
  22. Retakes recorded last month Number
  23. Shielding and exposure monitoring Rating
    • Complete and current 5 pts
    • In place with gaps in records or badge use 3 pts
    • Missing or not used 1 pt

3. Nitrous system 21 items

  1. Type of nitrous oxide system Choice
    • Central piped manifold
    • Portable units
    • Both
  2. Nitrous oxide and oxygen cylinders are secured upright with a chain, strap or stand Yes / No 1 pt
  3. The cylinder storage room is ventilated and free of oil, grease and combustible materials Yes / No 1 pt
  4. Full and empty cylinders are stored apart and tagged Yes / No 1 pt
  5. Gas-specific connectors (pin-index or diameter-index) are intact, and no adapters are in use Yes / No 1 pt
  6. The oxygen fail-safe was tested in the last 12 months: nitrous oxide flow stops when oxygen flow stops Yes / No 1 pt
  7. The flowmeter cannot deliver less than 30% oxygen Yes / No 1 pt
  8. The oxygen flush button works on each unit Yes / No 1 pt
  9. Reservoir bags are free of cracks and tears Yes / No 1 pt
  10. Breathing hoses and their connections are free of cracks Yes / No 1 pt
  11. High-pressure connections are leak-tested with soap solution at each cylinder change Yes / No 1 pt
  12. Date of the last leak test Date
  13. The low-pressure alarm panel of the manifold works and can be heard in the clinical area Yes / No 1 pt
  14. Zone shut-off valves are labeled and unobstructed Yes / No 1 pt
  15. The nitrous oxide system was serviced by a qualified technician within the interval set by its maker Yes / No 1 pt
  16. Date of the last service of the nitrous oxide system Date
  17. Cylinder valves or the manifold are closed at the end of each day Yes / No 1 pt
  18. A working pulse oximeter is available in each room where nitrous oxide is given Yes / No 1 pt
  19. A bag-valve-mask connected to emergency oxygen is available in the treatment area Yes / No 1 pt
  20. A patient receiving nitrous oxide is never left alone in the operatory Yes / No 1 pt
  21. Condition of the nitrous oxide delivery system Rating
    • All components in good working order 5 pts
    • Minor defects not affecting safety 3 pts
    • Defects affecting safety 1 pt

4. Scavenging 19 items

  1. Each nitrous oxide station has a scavenging nasal mask connected to the vacuum system Yes / No 1 pt
  2. Nasal masks are stocked in child and adult sizes Yes / No 1 pt
  3. The scavenging flow is set to the rate given by the system's maker (commonly 45 L/min) Yes / No 1 pt
  4. Scavenging flow measured at the station checked (L/min) Number
  5. The scavenging vacuum exhausts outdoors, away from air intakes and windows that open Yes / No 1 pt
  6. The operatory ventilation exhausts room air rather than only recirculating it Yes / No 1 pt
  7. The scavenging vacuum is switched on before nitrous oxide flow starts Yes / No 1 pt
  8. The reservoir bag was neither collapsed nor overfilled during the administration observed Yes / No 1 pt
  9. Patients are asked to breathe through the nose and limit talking while nitrous oxide flows Yes / No 1 pt
  10. The patient is given 100% oxygen for at least 5 minutes before the mask is removed Yes / No 1 pt
  11. Scavenging masks and hoses are checked for cracks before each use Yes / No 1 pt
  12. Single-use nasal hoods are discarded after one patient, and reusable hoods are sterilized Yes / No 1 pt
  13. Nitrous oxide in the room air is measured with personal samplers or an analyzer on the schedule set by company policy Yes / No 1 pt
  14. Date of the last measurement of nitrous oxide in room air Date
  15. Highest time-weighted result at the last measurement (ppm) Number
  16. The last results were below the exposure limit adopted in company policy Yes / No 1 pt
  17. Results above the limit led to a recorded corrective action and a new measurement Yes / No 1 pt
  18. No hissing was heard at connections or hoses during the administration observed Yes / No 1 pt
  19. Control of waste nitrous oxide Rating
    • Scavenging working and exposure measured 5 pts
    • Scavenging working, exposure not measured 3 pts
    • Scavenging missing or not used 1 pt

5. Training 16 items

  1. Employees who take radiographs Number
  2. Each employee who takes radiographs holds the certificate required by local regulation Yes / No 1 pt
  3. Radiation safety training is given at hire and repeated within the interval set by company policy Yes / No 1 pt
  4. Date of the last radiation safety training Date
  5. An employee asked could show where to stand during an exposure Yes / No 1 pt
  6. An employee asked could explain when the child settings are used Yes / No 1 pt
  7. Operators of the handheld x-ray unit were trained on that model Yes / No 1 pt
  8. Operators of the cone beam unit completed the manufacturer's training Yes / No 1 pt
  9. Each dentist or hygienist who administers nitrous oxide holds the permit required by local regulation Yes / No 1 pt
  10. Employees who assist with nitrous oxide sedation completed the training required by local regulation for their role Yes / No 1 pt
  11. A medical emergency drill that included an over-sedated patient was held in the last 12 months Yes / No 1 pt
  12. Date of the last medical emergency drill Date
  13. An employee asked could show the zone shut-off valve for nitrous oxide Yes / No 1 pt
  14. Cylinders are changed only by employees trained to do so Yes / No 1 pt
  15. Employees were informed of the health effects of long-term exposure to nitrous oxide Yes / No 1 pt
  16. Knowledge of the employees asked Rating
    • Confident and correct 5 pts
    • Partly correct 3 pts
    • Unable to answer 1 pt

6. Records 18 items

  1. The radiation safety officer is named in writing Yes / No 1 pt
  2. Name of the radiation safety officer Short text
  3. The written radiation protection program is available to every employee who takes radiographs Yes / No 1 pt
  4. Inspection reports are kept for the period required by local regulation Yes / No 1 pt
  5. Dosimetry reports are kept for the period required by local regulation Yes / No 1 pt
  6. Service and repair records are on file for each x-ray unit Yes / No 1 pt
  7. Each of 5 charts sampled records the dentist's order and the number of radiographs taken Yes / No 1 pt
  8. Each of 5 nitrous oxide charts sampled records the concentration given and the duration Yes / No 1 pt
  9. The nitrous oxide charts sampled record the oxygen given at the end of the procedure Yes / No 1 pt
  10. A signed consent for nitrous oxide is on file in each chart sampled Yes / No 1 pt
  11. The nitrous oxide charts sampled record the patient's vital signs before and after the procedure Yes / No 1 pt
  12. Each monitored employee has been shown their own dosimetry results Yes / No 1 pt
  13. Equipment malfunctions and sedation incidents are recorded on an incident report Yes / No 1 pt
  14. Radiation or nitrous oxide incidents recorded in the last 12 months Number
  15. The written radiation protection program was reviewed in the last 12 months Yes / No 1 pt
  16. Corrective actions from the previous inspection have been completed Yes / No 1 pt
  17. Overall radiography and nitrous oxide safety Rating
    • Meets standards 5 pts
    • Meets most standards 3 pts
    • Below standards 1 pt
  18. Findings and corrective actions Comments

About this template

This checklist is part of the Bindy template library. Yes / No checks score 1 point when met; ratings score the points shown for each option. The overall score is the percentage of points earned, with N/A answers excluded. In Bindy you can add photos, assign corrective actions, require sign-off and compare results across sites.

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