Clinical record keeping – are we doing it properly?

Key Points

• A voluntary structured programme can result in improved clinical record keeping.

• Significant improvements can be achieved in the recording of periodontal disease, caries and the patient's perception of pain, aesthetics and function.

• Diagnosis and presenting complaint were consistently well recorded before and after the programme was introduced.

• Written treatment alternatives were poorly recorded and no significant change was achieved as a result of introducing the pilot programme.

Abstract

Background Denplan is a private capitation-based system of providing primary dental care in the UK. An additional programme called Denplan Excel has been developed which requires General Dental Practitioners to instigate various quality processes within their practices in order to become accredited. Clinical record keeping is one area where standards are monitored. This study reports changes in record keeping at patient recall appointments following the implementation of the Denplan Excel programme.

Method Fifty dentists participating in the Denplan Excel pilot programme from different areas of the UK were sampled by means of cluster sampling. Twenty records for each dentist were sampled and items recorded for patients recalled both pre- and post-pilot were compared.

Results The majority of dentists recorded presenting complaint, diagnosis and treatment plan both pre- and post-pilot. However, post-pilot there were a number of improvements in record keeping. Caries recorded on a grid increased from 7% of records to 46%, basic periodontal examination increased from 48% to 85% of records and the updating of medical history increased from 51% to 65% of records. These findings were all significant at the p < 0.01 level.

Conclusion Changes can be achieved by voluntary participation in a system of structured record keeping.

Main

Clinical record keeping by general dental practitioners piloting the Denplan 'Excel' Accreditation Programme by R. S. Ireland, R. V. Harris, and R. Pealing Br Dent J 2000; 191: 260–263

Comment

This paper concerns record keeping in General Dental Practice and the changes that occurred in the accuracy and completeness after the introduction of a new approach and methodology of paper records. The defence societies continue to give exhortations to keep accurate and comprehensive clinical records but there is a widespread professional view that record keeping could be improved upon. In a study carried out by two dental reference officers in Scotland, 52% of tooth charting on the dental records supplied did not equate with the clinical examination. Indications were that the dental charting had not been regularly updated.

In this study 50 dentists were drawn from the 676 participants in the Denplan Capitation Scheme who had volunteered to pilot a development of the capitation scheme. This development of the Excel programme focuses on quality management and patient information and communication. The subjects were therefore from a self-selected group who by inference had, by their actions, already identified themselves as committed to a high standard of patient care. Undertaking the Excel Programme committed them to changes within their practices, a degree of self-appraisal and training for themselves and their staff coupled with external monitoring. More importantly the programme provided the practices with a specifically designed paper record keeping system which incorporated a method for encouraging regular updating of charting, oral status including mucosal and periodontal examination and medical history.

This study examined a sample of the selected dentist's clinical records. The records selected for examination were from those patients who had been subject to two recall examinations, one of which was before the introduction of the new scheme. Appropriate coding both of patient records and the dentist's identity was carried out to maintain confidentiality. Interestingly the samples for each dentist consisted of 20 consecutive patients, presumably these were patients attending for a recall visit perhaps the '6-month check-up'. Ten per cent of the dentists were re-sampled to confirm reproducibility. The study showed that the standard of record keeping relating to specific items required by the Excel system had improved. Around half of the dentists were recording the results of the Basic Periodontal Examination (BPE) before their introduction to Excel, after it another third were complying with the requirement.

Before the programme a disappointing 93% of dentists did not record caries on a chart, this fell to 46% after the programme. That the Oral Health Score, a composite measure derived form several items of the clinical examination was recorded in 90% of the records after the introduction demonstrated the level of compliance with the scheme.

The question remains; can this be extended to dentists in general? The dentists involved were self-selecting and motivated, a new record system was provided and they and their staff had had further training in its use. To be part of the programme they had to agree to a degree of monitoring by peer review. To bring about such an improvement nationwide by reproducing these requisites would be a challenge.