Abstract
To evaluate the quality of clinical records as a measure of quality of paediatric oral health care in a tertiary health institution, in Nigeria. A 12-month retrospective review of clinical records of all paediatric dental patients seen in the dental centre of a tertiary hospital in Nigeria was carried out. The clinical records were assessed using a structured standard checklist based on the modified CRABEL Scores. The information assessed in each of the case notes included the case note identification number, patient demographic information, the history of presenting complaint, dental and medical /drug histories. Other information elicited were clinical features, diagnosis, treatment plan, procedures done and professional rank of the person who made the entries. Scores obtained per item for each case note were inputted and analyzed using the Statistical Package for Social Sciences (SPSS) Version 20.0. Three hundred and thirty four clinical records were assessed, of which, 136 (44.3%), 106 (36.8%), 65 (21.2%) and 7 (2.3%) of entries were made by students, interns, resident doctors and consultants respectively. The median CRABEL score was 95%. Written consent was the least (0.3%) documented information. There were statistically significant differences between the professional rank and extra oral examination, treatment plan and procedures done (p<0.05). However, there was no significant difference between the professional rank and CRABEL scores (p=0.4). Using the adequacy of clinical note taking as an index of the quality of care, it may be concluded that the quality of care in our paediatric dental clinic is of high standard. The only shortcoming in our experience was almost the absence of documentation of written informed consent.
Highlights
Oral health cannot be separated from general health; it has been described as an essential part of the total health of a child or an adolescent [1]
Three hundred and thirty four clinical records were assessed during the study, of which, 136 (44.3%), 106 (36.8%), 65 (21.2%) and 7 (2.3%) of entries were made by students, interns, resident doctors and consultant, respectively
The records fell into different grades of Joycelyn Odegua Eigbobo et al.: Assessment of the Quality of Care at the Paediatric Dental Clinic of a Tertiary Health Institution in Nigeria quality as determined by the CRABEL scores
Summary
Oral health cannot be separated from general health; it has been described as an essential part of the total health of a child or an adolescent [1]. The quality of care obtainable can be assessed directly through prospective observation by a trained observer or indirectly by retrospective review of clinical records [4]. Information obtained from the records are useful for medico-legal reasons, forensic purposes [5], planning, and research, their significance in the assessment of quality of care cannot be overlooked [6, 7]. It has been shown that there is a relationship between the quality of documentation in case files and quality of dental care [6, 8]. The treatment plan, treatments carried out, follow-up and home care instructions are documented
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