Audit of dental record-keeping at a university dental hospital

Abstract

Background: Good record-keeping is fundamental in clinical practice and essential for practising dental practitioners and those in training.

Aim: This study aimed to evaluate the level of compliance with clinical record-keeping by undergraduate dental students and staff at a university dental hospital.

Setting: The selected study setting was the Admissions and Emergency section at a university dental hospital.

Methods: A retrospective, cross-sectional review was undertaken of 257 clinical records. The CRABEL scoring system was used to evaluate 12 variables. The 12 variables included: patient name, patient hospital number, date of examination, patient main complaint, medical history, dental history, proposed treatment, proposed procedure for next visit, patient consent signature, treatment and treatment codes, student name and signature, clinical supervisor name and signature. STATA® 13 was used for descriptive analysis and all tests were conducted at 5% significance level.

Results: The median CRABEL score was 87 and interquartile range (IQR: 70–92). A CRABEL score of 100 was achieved by the students in the variable patient main complaint, indicating a 100% compliance with this variable. Other variables such as signature of supervisors showed poor compliance. The CRABEL scores showed no statistically significant difference (p = 0.86) between the students and clinical supervisors.

Conclusion: The overall audit showed that there was poor compliance with record-keeping.

Contribution: The study highlights the importance of good record keepings so that key information can be accessed for proper diagnosis and treatment of the patient. An electronic filing system presents an alternative manner of documenting medical records.