Clinical Audit Teaching in Record-Keeping for Dental Undergraduates at International Medical University, Kuala Lumpur, Malaysia

Assessing the Recordkeeping Quality at the School of Dental Sciences, Universiti Sains Malaysia

INTRODUCTION

 Dental records are an essential part of dental practice. The quality of dental recordkeeping is paramount in ensuring the delivery of high-quality dental care and is also important for medico-legal reasons. Should there be any dispute or need for review, detailed and well-maintained records can provide evidence of the care provided and the decision-making process.

OBJECTIVE

The study aimed to assess the quality of dental recordkeeping and dental charting practice at the dental clinic School of Dental Sciences.

METHODS

The study was conducted in a retrospective manner reviewing dental records of patients treated by specialists, dental officers, and postgraduate and undergraduate students at the Hospital Universiti Sains Malaysia over a five-year period. Eight key components of clinical dental records i.e. date of charting, legibility on the odontogram, no blank on the odontogram, whether any mistakes have been strikethrough and initials, medical history, dental history, investigation, and treatment plan were assessed. A modified CRABEL scoring system was used to assess the quality of data retrieved from dental records.

RESULTS

The study involved the analysis of 324 case files. Among these, 90 files obtained scores ranging from 60% to 80%, with 7.7% attributed to undergraduates, 9.6% to dental officers, 6.8% to postgraduates, and 3.7% to specialists. The remaining 234 files achieved scores between 80% and 100%, with a breakdown of 17% from undergraduates, 15.4% from dental officers, 18.2% from postgraduates, and 21.3% from specialists.

CONCLUSION

 Even though the overall quality of recordkeeping in this study is good, with most records achieving a CRABEL score of 80% and above, it's important to acknowledge that ideally, each component assessed should achieve a perfect score of 100%, as it will reflect the practitioners's work.

Clinical audit of orthodontic chart documentation by dental undergraduates

INTRODUCTION

Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through the systematic review of care against explicit criteria and the implementation of change. The objective of this audit was to evaluate the quality of orthodontic chart documentation by dental undergraduates against established guidelines.

MATERIALS AND METHODS

An audit checklist with 13 criteria for good documentation was adapted from guidelines proposed by the American Association of Orthodontists and British Orthodontic Society. Orthodontic chart documentation in 103 removable appliance therapy patients under 4th and 5th year dental undergraduates' care was retrieved from the electronic record of the University dental clinic and audited. The audit exercise explored in detail the thirteen criteria for good documentation and eight assessment attributes of the first criterion, namely, basic orthodontic examination. The level of compliance was measured as the percentage records meeting the criteria. The data were statistically analysed using SPSS 26.0 (SPSS, Inc., Chicago, IL, USA).

RESULTS

There was no complete compliance for any of the criteria. Thirty-five (33.9%) patient charts reported basic orthodontic examination documentation adequately. Compliance was the highest for documentation of treatment modality (77.6%), appliance delivery encounters (77.6%), and appliance adjustment appointments (83.5%). About 51.4% of the 68 patient charts (treatment of 35 patients of the total 103 were in the progress stage) stated adequately the outcome of treatment. Only 22% of the 68 patient charts had the details for retention protocol. There was statistically significant difference in chart documentation between male and female students for basic orthodontic assessment and appliance delivery and patient instructions attributes.

CONCLUSION

The clinical audit demonstrated poor compliance with the criteria for orthodontic chart documentation. The audit should be repeated after the provision of learning opportunities and self-critical analysis.

Quality of endodontic record-keeping and root canal obturation performed by final year undergraduate dental students: An audit during the COVID-19 pandemic

BACKGROUND

To assess the quality of endodontic record-keeping and root canal obturation performed by undergraduate final year dental students during the COVID-19 pandemic.

MATERIALS AND METHODS

Dental records and dental radiographs of patients who received endodontic treatments between March 2020 and March 2022 by undergraduate students during the COVID-19 pandemic were included. The audit data were collected based on the European Society of Endodontology guidelines retrospectively via assessing the patient's clinical records and intraoral periapical radiograph. Root canal obturation quality was evaluated based on the following parameters: adaptation, length, taper, and mishap. A root filling is defined as satisfactory only when all four parameters were graded as acceptable. Subsequently, the data were recorded and analysed using Chi-Square test with the level of significance set at p = 0.05.

RESULTS

A total of 111 patient records with 111 root canal-treated teeth were evaluated. The highest percentage of documented evidence was noted in the patient's general records, while the endodontic treatment records showed the lowest percentage of documented evidence. 78 (70.3%) of root canal-treated teeth were deemed satisfactory with acceptable adaptation, length, taper, and absence of mishap. Moreover, no statistical significance in terms of root canal filling quality was noted between anterior and posterior teeth, and between maxillary and mandibular arch.

CONCLUSIONS

Although patient records and root canal fillings quality were deemed satisfactory in most cases, strict documentation requirements and continuing dental education in audit training are necessary for quality assurance.