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

Abstract

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.