ABSTRACT
Background: Good record-keeping is fundamental in clinical practice and essential for practising dental practitioners and those in training. Aim: This study aimed to evaluate the level of compliance with clinical record-keeping by undergraduate dental students and staff at a university dental hospital. Setting: The selected study setting was the Admissions and Emergency section at a university dental hospital. Methods: A retrospective, cross-sectional review was undertaken of 257 clinical records. The CRABEL scoring system was used to evaluate 12 variables. The 12 variables included: patient name, patient hospital number, date of examination, patient main complaint, medical history, dental history, proposed treatment, proposed procedure for next visit, patient consent signature, treatment and treatment codes, student name and signature, clinical supervisor name and signature. STATA® 13 was used for descriptive analysis and all tests were conducted at 5% significance level. Results: The median CRABEL score was 87 and interquartile range (IQR: 7092). A CRABEL score of 100 was achieved by the students in the variable patient main complaint, indicating a 100% compliance with this variable. Other variables such as signature of supervisors showed poor compliance. The CRABEL scores showed no statistically significant difference (p = 0.86) between the students and clinical supervisors. Conclusion: The overall audit showed that there was poor compliance with record-keeping. Contribution: The study highlights the importance of good record keepings so that key information can be accessed for proper diagnosis and treatment of the patient. An electronic filing system presents an alternative manner of documenting medical records.
Subject(s)
Humans , MaleABSTRACT
Background: Record keeping is an essential process and its importance cannot be ignored when it comes to Orthodontics. Even diagnosis is dependent on accurate and reliable Orthodontic records. Apart from diagnosis and treatment planning, these records are also important for medico-legal issues, publications, self -appraisals, patient education. The Basic record keeping armamentarium in Orthodontics includes: Case history, consent forms plaster models, a panoramic radiograph, Lateral cephalogram, intra and extra oral pictures. The objective of this study was be to determine the knowledge and Practice trend of Orthodontic record keeping amongst the dental practioners.Material & Methods:This cross-sectional study was conducted across various dental clinics in Bangalore city. The sample selection for Dental clinics was made by the lottery method, and total of 40 clinics were selected from the list of registered dental clinics. Questionnaires were designed in such a way so as to determine the knowledge, awareness and practice trends about the Orthodontic records keeping among dental practitioners. Questionnaires were collected back by hand and analysed. The data was tabulated in excel sheet and statistical analysis was performed on the data.Results:Chi-square/ Fisher Exact test has been used to find the significance of study parameters on a categorical scale between two or more groups. Student t-test has been used to find the significance of study parameters on a continuous scale between two groups (Intergroup analysis) on metric parameters. 65% practitioners didn’t attend any CDE program on maintaining health records program whereas 35% had attended such program’s. Majority of general practitioners had knowledge and awareness about Orthodonticrecord keeping while as practice of Orthodontic record keeping was not completely as per norms.Conclusion:The present study found the good knowledge and awareness about orthodontic record keeping, but record keeping practice was found to be average due to lack of adequate infrastructure at clinics and non-usage of digital technology in most of the clinics . This study suggests that more awareness programs stressing the importance of Orthodontic record taking and workshops for incorporating digital technology related to the storage & preservation of Orthodontic record should be conducted.
ABSTRACT
No que refere o tempo de conservação dos documentos clínicos, a legislação em Portugal é esparsa, com referências sobre a conservação em diversos diplomas legais, o que contribuiu para o desconhecimento de grande parte dos profissionais da saúde e gestores de instituições de saúde o período em que encontram-se obrigados a conservar as informações dos seus pacientes. Já no Brasil apesar da ausência legislativa o Conselho Federal de Medicina, através de Resoluções vem consolidando a temática. Ambos os países encaminham-se a favor da guarda permanente, que só pode ser alcançada através da mudança do suporte de papel para o suporte eletrônico.
Regarding medical record keeping, legislation in Portugal is sparse in relation to conservation of several legal instruments. Furthermore, it contributes to the knowledge of most health professionals and health institution managers who are obliged to keep the information of their patients. In Brazil, despite the absence of legislation, the Federal Medical Council has been consolidating the theme through resolutions. Both countries are heading to rule in favors of permanent guard, which can only be achieved by switching paper support for electronic support.
En lo referente al tiempo de conservación de los documentos clínicos, la legislación portuguesa es escasa, con referencias a la conservación a varios documentos legales, lo que contribuyó a la ignorancia de la mayoría de los profesionales de la salud e instituciones de salud del periodo en el que están obligados a mantener la información de sus pacientes. En Brasil a pesar de la ausencia legislativa del Consejo Federal de Medicina, a través de resoluciones ha venido consolidando el tema. Ambos países se dirigen a favor del archivo permanente, que sólo se puede lograr cambiando el soporte físico para el soporte electrónico.
ABSTRACT
Worldwide, for an estimated 358,000 women, pregnancy and childbirth end in death and mourning, and beyond these maternal deaths, 9-10% of pregnant women or about 14 million women per year suffer from acute maternal complications. This paper documents the types and severity of maternal and foetal complications among women who gave birth in hospitals in Matlab and Chandpur, Bangladesh, during 2007-2008. The Community Health Research Workers (CHRWs) of the icddr,b service area in Matlab prospectively collected data for the study from 4,817 women on their places of delivery and pregnancy outcomes. Of them, 3,010 (62.5%) gave birth in different hospitals in Matlab and/or Chandpur and beyond. Review of hospital-records was attempted for 2,102 women who gave birth only in the Matlab Hospital of icddr,b and in other public and private hospitals in the Matlab and Chandpur area. Among those, 1,927 (91.7%) records were found and reviewed by a physician. By reviewing the hospital-records, 7.3% of the women (n=1,927) who gave birth in the local hospitals were diagnosed with a severe maternal complication, and 16.1% with a less-severe maternal complication. Abortion cases—either spontaneous or induced—were excluded from the analysis. Over 12% of all births were delivered by caesarean section (CS). For a substantial proportion (12.5%) of CS, no clear medical indication was recorded in the hospitalregister. Twelve maternal deaths occurred during the study period; most (83%) of them had been in contact with a hospital before death. Recommendations include standardization of the hospital record-keeping system, proper monitoring of indications of CS, and introduction of maternal death audit for further improvement of the quality of care in public and private hospitals in rural Bangladesh.