DENTAL AUDIT


How’s your record keeping?


Dr Terry Simpson champions a new audit tool for assessing the quality of dental records


T


IME and time again we are told of the importance of record keeping and perhaps it is best firstly to consider why we need good records. Te British Dental Association in its advice sheet on record keeping views it as fulfilling the following purposes: • patient safety • monitoring • accounts • probity enquiries • evaluation of treatment.


However, the General Dental Council in its Standards for dental professionals is more vague, stating only: “Make and keep accurate and complete patient records, including a medical history, at the time you treat them. Make sure that patients have easy access to their records.”


Many dentists will admit to deficiencies when recording some of the information that is now generally accepted as comprising a good clinical record. Very oſten time is cited as the reason; sometimes dentists only see positive findings as requiring any detail. Whatever the reason, it is clear that it is our responsibility to maintain good contemporaneous and complete notes from clinical encounters.


Te incompleteness of clinical records is very much supported in the evidence we have available from published audits. In 2001, an audit looking at the records from 47 general dental practitioners entering the quality assurance programme of a private capitation scheme (BUPA) in England and Wales found various deficiencies1


.


Tese records were examined by an independent assessor and measured against seven different domains for which a standard was identified, including medical history, examination of soſt tissues, full tooth charting, periodontal screening,


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at-risk periodontally and pocket depth chart, diagnosis and treatment planning. Te results showed dentists only to have achieved more than 50 per cent of target frequency of recording in one domain – full tooth charting (70 per cent). Completed medical histories were only available in 45 per cent of clinical records and worst of all nearly 80 per cent of patients had no periodontal screening at all.


Another audit from 2009 showed an improving picture but still with some deficiencies2


. However,


unlike the 2001 audit, the method employed in this study was self-assessment, which is largely dependent on how well calibrated and rigorous the assessors were in applying the criteria. If, indeed, the quality of clinical records is improving, we have the defence societies and professional bodies such as the Faculty of General Dental Practitioners to thank for continually preaching the importance and assisting us in achieving a better standard.


Lothian Record Keeping Audit In two previous Summons articles a thoughtful case was presented for incorporating clinical audit and significant event analysis (SEA) into everyday practice (see 2010 Summer and Autumn issues at mddus.com). Tese sentiments have been similarly recognised by the Quality Improvement Team for Dentistry in Lothian (Lothian Committee for Quality in Dentistry – LCQD). In April 2009 the committee commissioned an audit on clinical documentation standards that could be used by all dental professionals. Tis audit was to use the planned updated standards issued by the Faculty of General Dental Practitioners (FGDP) as the basis for the audit. Te following year the protocol and data- gathering tool were approved by LCQD for


“Many dentists will admit to deficiencies when recording some of the information that is now generally accepted as comprising a good clinical record ”


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