Education abstract
British Dental Journal 197, 703 - 705 (2004)
Published online: 11 December 2004 | doi:10.1038/sj.bdj.4811866
Record keeping by undergraduate dental students: A clinical audit
- Accurate record keeping will ensure appropriate and systematic flow of the treatment plan. This is of importance especially in dental schools where loss of valuable clinical time can be minimised.
- Undergraduate students will have a better understanding of the treatment plan and the reasons behind it, if the records are accurate.
- Dental schools play a major role in developing the record keeping skills of future practitioners.
- Dental record keeping has become increasingly important particularly for research, audit and medico-legal purposes.
Abstract
Aims and objectives: An audit was carried out to assess the standard of clinical record keeping by undergraduate dental students, with the object of improving the quality of care of patients treated by these students.
Methodology: One hundred sets of undergraduate student clinical treatment records were evaluated against a modified CRABEL scoring system. The results of this initial part of the audit were presented in tutorial form to a group of 20 students, together with a teaching session on good record keeping, after which the audit was repeated, and another 100 records were examined over five consecutive Fridays, thus completing one complete audit cycle.
Results: The most commonly absent record related to the department where the patient was seen followed by illegible signatures of both the demonstrator and the student. Almost all elements of record keeping investigated had improved in the second audit, most reaching 100% compliance, except for two (the updated medical history and the patient's most recent complaint).
Conclusion: Positive changes can be achieved by creating awareness among dental students on the importance of keeping records.
- Specialist Prosthodontist, Dental Polyclinic, St Thomas' Hospital, London, SE1 7EH
- Consultant in Restorative Dentistry, Maxillofacial Unit, Queen Alexandra Hospital, Portsmouth, PO6 3LY
Correspondence to: F Pessian1 Dental Polyclinic, St Thomas' Hospital, SE1 7EH