Audit of record keeping by students and staff at Wits Oral Health Centre admissions and emergency department

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2020

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Taunyane, Keitumetse

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Introduction: Good record keeping is fundamental in clinical practice and essential for training and practising dental practitioners. Objectives: To determine the standard, and evaluate level of compliance of clinical record keeping by undergraduate dental students and staff at Wits Oral Health Centre. Methods: A retrospective, cross-sectional review of 257 patients’ records was under taken. The CRABEL scoring system was used to evaluate 12 variables, scored according their weights to yield a score of 100. STATA® 13 was used for descriptive analysis and all tests were conducted at 5% significance level. Results: The median CRABEL score was 87 and IQR (70 – 92). Only 7.4% of the records achieved a CRABEL score of 100. None of the variables achieved an overall full compliance of 100%. No statistical significant differences were found between the students and clinical supervisor records, p ≥0.05. Conclusion: The overall audit of the records showed poor level of compliance.

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A research report submitted in partial fulfilment of the requirements for the degree of Master of Dentistry in the branch of Orthodontics, in the Department of Orthodontics, School of Oral Health Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2020

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