Quality assurance and dental patient records

Kopsala, Jaana Tellervo
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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.