Audit of dental record-keeping at a university dental hospital
Health SA Gesondheid (Print)
;
28: 1-5, 2023. tables
Artigo
em Inglês
| AIM
| ID: biblio-1524442
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.
Texto completo:
DisponíveL
Índice:
AIM (África)
Tipo de estudo:
Estudo observacional
Limite:
Humanos
/
Masculino
Idioma:
Inglês
Revista:
Health SA Gesondheid (Print)
Ano de publicação:
2023
Tipo de documento:
Artigo
Instituição/País de afiliação:
Department of Orthodontics, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa/ZA
/
Department of Orthodontics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa/ZA
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