Quality assurance and dental patient records
Date
2014-04-30
Authors
Kopsala, Jaana Tellervo
Journal Title
Journal ISSN
Volume Title
Publisher
Abstract
A well designed, adequately documented and properly maintained patient record is an
important tool for quality assurance. The aim of this cross-sectional, descriptive study is
to specify and quantify the adequacy of dental patient record keeping and its usefulness
for quality assurance purposes. Two study sites were chosen: Alexandra Public Dental
Clinic in the township of Alexandra, Johannesburg, and the Department of Restorative
Dentistry, University of the Witwatersrand, Johannesburg. The study population
included all patients who attended either clinic in 1998 and 1999. One hundred names
qualified for inclusion from the 400 names randomly drawn from the records of the
Department of Restorative Dentistry and another 100 from the random selection of 120
names from the Alexandra Clinic. A validated check-list encompassed eight key areas as
follows: patient identification, medical, and dental history, clinical examination,
radiographs, diagnosis, treatment plan and progress notes. This was used to measure the
adequacy of dental patient record keeping.
The patient records of both groups had incomplete and inconsistent documentation.
Information such as the identity of patients, diagnosis, treatment plan and procedure,
materials used, and radiographic information were often missing. Non-existent record
cards and often incomplete and inconsistent information gathering reflected a lack of
attention to, and standardisation of, dental record keeping in these two study sites.
Adequate patient records lead to complete and accurate documentation of the dental care
process. At both study sites, the patient record form needed to be revised in order to meet
standard requirements.
In general, documentation at both clinics was poor. None of the patient records fulfilled
all the variables included in the study. At the Alexandra Clinic patient records were
deficient in documentation in all sectors. The Department of Restorative Dentistry
provided patient records that adequately demonstrated the dental care process, but were
lacking in accuracy and completeness. Lack of standardisation and non-uniformity of
information was evident at both of the clinics.
Adequate patient records that are completed correctly provide the basis for assessment of
the dental care process. The problem orientated approach to dental care is best assured by
using dental patient records which divide the dental care process into four particular
categories: the assessment, the diagnosis, the treatment plan and the provision of
treatment. At the Alexandra Clinic, the inadequate patient records apparently contributed
to inferior documentation of the dental care process. Documentation style also reflected
the given treatment regime, which was mainly pain relief procedures. The dental patient
record at the Alexandra Clinic did not follow the problem orientated approach, leaving
most o f the burden on adequate documentation for the oral health care professional to
demonstrate the dental care process. Lack of understanding of the purpose of complete
and accurate documentation was evident at the Department of Restorative Dentistry.
Owing to inadequate patient record design at the Alexandra Clinic, and due to inadequate
documentation in both of the clinics, it was impossible to use dental patient records for
quality assurance purposes. Whether these deficiencies affect the quality of care can only
be speculated.
The patient record is a very important prerequisite for quality assurance in dental care.
The government and the professional organisations such as the Health Professions
Council of South Africa and the South African Dental Association should be largely
Tegi- .visible for the creation, implementation and monitoring of the policies for quality
assurance. These institutions jointly should promulgate rules about adequate patient
record keeping. There is a further need for better training in formulary for dental students
and postgraduates. There is also a necessity for more intensive monitoring and evaluation
in the field.