Clinical Audit and Record Keeping Guide for Improving Patient Care

Abstract

BACKGROUND Maintaining records and documentation of all aspects of patient's dental care is considered as the legal responsibility and professional duty of the dental surgeon. Complete dental records consist of documents pertaining to history of present illness, clinical examination, diagnosis, treatment plan, treatment provided and prognosis. Record maintenance helps in all the aspects of practice whether providing appropriate treatment or medicolegal defence. MATERIALS AND METHODS We conducted thorough research of documents pertaining to patients who reported to the Department of Oral and Maxillofacial Surgery, KLES V.K. Institute of Dental Sciences, Karnataka, India, between 2015-2016.Their records were maintained in the prescribed format followed by entry in a register about the records, diagnosis, treatment which was crosschecked by a consultant daily.The record consist of several different elements, which include written notes, radiographs, study models, referral letters, consultants reports, clinical photographs, results of special investigations, drug prescriptions, laboratory prescriptions, patient identification information and a comprehensive medical history. Timely auditing was done to evaluate the quality of care provided with constant refinement of the protocols RESULTS The audit of the records done in our department showed the common mistakes in recording history by the trainees. We recorded common postoperative complications seen with different procedures and treatment protocols.Wherever required protocols and follow ups were changed to minimise them. With the help of this audit, we were able to compare new treatment modalities and were able to provide best possible care which was also cost effective. CONCLUSION This article highlights the importance of dental records and how it helps in improving patient care, especially in developing countries where this habit is to be inculcated from roots now. It gives an insight into the possible success rates to be encountered by general dental practitioners by continuous review and audit of their work especially benefitting when applied at level of institution.

Analysis of endodontic dental records of patients who were treated in a public university in south of Brazil

“…The accurate registration of the patient information allows for improving the quality of care. Clinical audit including education can favorably change treatment rendered by dental practitioners (Motimath et al, 2017).…”