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Pakistan Oral and Dental Journal. 2016; 36 (1): 38-41
in English | IMEMR | ID: emr-179043

ABSTRACT

An audit was conducted at Hamdard University Dental Hospital to assess the standard of clinical record keeping by undergraduate dental students, house officers and faculty members. Objective of this audit was to improve the quality of care of patients treated by the staff and students


100 hospital notes were audited for this purpose. These records were randomly selected from the record room at HUDH. CRABEL score was used for assessing the quality of these notes


Ten variables were measured in our study. Data analysis was done on SPSS version 16. Descriptive statistics were performed. Mean CRABEL score was found to be 50


94% of the notes had readable writing. 87% of the clinical notes did not mention the chief complaint of the patient. 98% of the clinical notes had no mention of consent in them, while 43% of the clinical notes did not mention the investigations performed. These inferences clearly suggest that the current standards of clinical notes need considerable improvements. Further studies are planned in the future after addressing the present deficiencies


Subject(s)
Humans , Quality of Health Care , Medical Records , Students, Dental , Dental Audit , Medical Audit , Medical History Taking , Data Collection
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