Presentations 2020: Ortho&Paeds

357 - A two-cycle audit assessing the quality of clinical record keeping of dentists working within CDS.

NEEL SETHI
Presented by: Neel Sethi
St. David's Hospital

Introduction: In the CDS a lot of patients have complex medical and social histories and for these patients to be treated safely and appropriately detailed clinical records must be kept. Aim: The aim of this clinical audit was to assess the quality of clinical record keeping against a clearly defined standard. Method: The first audit cycle was completed in October 2019 where I randomly selected 10 exam appointments over at least 5 different days from each dentist. I assessed the quality of clinical record keeping against 10 parameters. For records to be deemed acceptable 8/10 of the parameters need to be met and I set the standard at 90%. After the initial audit it became evident that key information was not being recorded repeatedly during exam appointments. To ensure that information is not forgotten I created a template on ‘SOEL’ which included all 10 parameters being assessed. I emailed all dentists outlining the initial audit results and highlighting areas being missed. I explained how to locate and use the new template and I also presented my initial audit findings at a staff locality meeting where all Cardiff and Vale CDS staff attended. A second audit cycle was then completed in January 2020. Results: The results of the second audit cycle were very positive showing overall 80% of clinical records audited were deemed acceptable, which is an improvement from 60% in the first cycle. Also 5 out of the 6 dentists audited are now meeting the standard of 90% in comparison to 2 dentists after the first audit cycle and all parameters measured improved between the cycles. Conclusion: Overall although there was a significant improvement between the audit cycles, the standard has not been met so further training in record keeping is required prior to a third audit cycle.
Consent Statement: There are no details on individual patients reported within the abstract.

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