Evaluation of Record Keeping in Exodontia Department of Punjab Dental Hospital, Lahore: A Clinical Audit.

Abstract

An audit was conducted in the exodontia department of Punjab Dental Hospital, Lahore, to assess the quality of records being kept by the undergraduate students in their third and final year, who form a major chunk of the workforce in the hospital, working in the mentioned department. The main objective behind this exercise was to improve the standards of record keeping and bring them in line with the standards practiced around the world, ultimately resulting in better patient care. This audit was undertaken while keeping in view all the necessary steps of a successful clinical audit. Initially, 150 records were randomly obtained from undergraduates of both third and fourth years and evaluated against a modified CRABEL score, which grades the records on a scale of 100. The results of this part of the audit were shared with the batches thatwere doing their clinical rotation in exodontia at the time of this audit, and a teaching session was conducted on better record-keeping standards. Following this, a repetition of the previous audit was undertaken to complete the audit cycle. Results:The most commonly omitted component in the records in the initial audit was the patient complaint closely, followed by proper medical history and supervisor signatures. In the following, 'reaudit' compliance was seen to be improved, and all the components of record-keeping less commonly being omitted except medical history and date. A more comprehensive patient record keeping is possible with proper intervention and inculcation of record-keeping awareness in the undergraduate course, especially in the clinical years.