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Oral Care 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.
 
I understand routine oral cleansing and suctioning can help address three risk factors 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.
 
The Q·Care® system makes it easier to follow my unit’s oral care protocol.
 
 
 
 
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