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Lookup NU author(s): Dr Richard Holliday
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Objective: Good quality contemporaneous clinical records are an essential requirement of patient care. Foremost, it ensures good continuity of care but is also essential for medico-legal reasons. Our aim was to assess the quality and completeness of the record keeping within the Oral Surgery department, to highlight any deficiencies and put in place improvement measures if needed. Methods: Twelve criteria were identified relevant to the outpatient oral surgery setting: author, reason for attendance, presenting complaint, history of presenting complaint, medical history, dental history, social history, clinical examination, radiograph justification and report, diagnosis and treatment plan. Three rounds of audit were completed between January 2008 and January 2010, studying the records of 450 new patient consultations. Interventions include presenting results and discussing at departmental meetings/clinical governance meetings, using custom screens, ‘dummies guides’ and staff training. Results: From the first to the third round of audit, there was an improvement in 10 of the 12 criteria with an overall average improvement in compliance from 54% to 76%. There was deterioration in performance in two criteria over the three rounds: justification of radiographs and recording an evaluation of radiographs, -28% and -20% respectively. There was an overall improvement of 33% between the first and second round, with five criteria attaining 100% in the second round. A slight drop in performance was observed in the third round with none of the criteria achieving 100%. Eight per cent of the records in the first round fulfilled none of the criteria, falling to 3.5% in the third round; 5.5% and 1.5% in the first and third rounds respectively had ‘see letter’ as the only entry. Conclusions: This audit project has demonstrated a significant improvement in the quality and completeness of the clinical records, over the 2 years studied. Further interventions will be designed in an effort to achieve 100% compliance.
Author(s): Johnson S, Holliday R
Publication type: Article
Publication status: Published
Journal: Oral Surgery
Print publication date: 20/10/2010
ISSN (print): 1752-2471
ISSN (electronic): 1752-248X
Publisher: Wiley-Blackwell Publishing Ltd.
Notes: Conference Report
Joint Meeting of the British Association of Oral Surgeons and the European Federation of Oral Surgery Societies, Edinburgh 2010
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