Audit results summary sheet (poor records falling below acceptable standards are highlighted in red). This results table shows with 87% compliance that a target level would have been met for round one but not round two.
Extract from patient data sheet
distribution to all dentists in Lothian. Te remit was to produce an audit that: • was comprehensive, covering all aspects of record keeping
• set out the data sheet as a set of simple questions • allowed the data gatherer to answer questions as “Yes”, “No” or “Not applicable”
• resulted in one overall figure for compliance.
Having looked at several audits and the data- gathering tools that accompanied them, several points became apparent. Record keeping audits had concentrated on certain domains such as periodontal treatment and medical histories. Whilst using a domain-focused audit can be very useful, it would appear to miss the important first step of analysing all areas of record keeping, some of which might be overlooked, e.g. quality of referral letters, details of surgical procedures, etc. Tis approach can also be messy as there are different results for different domains. Having a single compliance figure overcomes some of these problems. In developing the Lothian audit data gathering tool it was decided to keep it simple with each “Yes”, “No” or “Not applicable” answer carrying the same weight and total compliance expressed as a percentage. It should be stressed at this juncture that before embarking on any audit an acceptable standard needs to be set by those involved in the project. Tis is up to the individual practitioner to decide but in the pilot studies the target for round one was set at 80 per cent and 90 per cent for round two. An example of the data gathered is shown in an extract from the data sheet above leſt. Tis shows the information split into several multi-part questions requiring a simple “Yes”, “No”
AUTUMN 2011
or “Not Applicable” answer. Changing any of the answers will automatically change the totals at the bottom of each column which are then used to calculate the total compliance.
Totals for each patient record audited can then easily be transferred to a results summary sheet (above right). By completing the results electronically, calculation can be made for each data sheet based on a compliance figure (Yes/Yes + No x 100%). When all 25 patient records are complete, an overall compliance figure for all patients can be attained.
All audits suffer to some extent from not weighting the data by importance. For example, would having a dog-eared written record card equate in importance to not having a current medical history – probably not? However, further refinements of the audit in future might allow weighting to be applied to the results and this would be a relatively simple tweak to incorporate into the data collection tool. It would be possible to adapt the audit further and weight each answer according to a system of desirable or essential outcomes. We hope the audit will continue to evolve and assist many dental practitioners for years to come!
n Dr Terry Simpson is a general dental practitioner and honorary research fellow at the University of Edinburgh. Terry would also gratefully like to acknowledge the contribution of the Clinical Governance Support Team at NHS Lothian and, in particular, Denise Needham in constructing and promoting this audit. He would also like to acknowledge NCAAG (National Clinical Audit Group in E & W) which piloted the initial spreadsheet design.
OBTAIN A COPY
Copies of the audit comprising instructions, protocol, data collection sheets (one per patient) and results summary sheets can be obtained in electronic version only by contacting Denise Needham at NHS Lothian
(
Denise.Needham @
luht.scot.nhs.uk). Printed sheets can be made from these if the data gatherer prefers but the data collection sheets fit best on A3 sheets or alternatively several landscape A4 sheets.
References
1 Morgan RG. Quality evaluation of clinical records of a group of general dental practitioners entering a quality assurance programme. Br Dent J. 2001;191:436-41
2 Cole A, McMichael A. Audit of Dental Practice Record- Keeping: A PCT-Coordinated Clinical Audit by Worcester- shire Dentists. Primary Dental Care. 2009;16:85-93
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