The importance of record keeping and the ward round: A review of practice and protocol for Dental Core Trainees in Oral & Maxillofacial Surgery

Abstract

Aim: The importance of clear and concise record keeping cannot be underestimated from both a medico-legal perspective and in the protection of patients. Oral and Maxillofacial surgery is unique among the medical specialities due to the provision (albeit under the provision of a dually qualified senior) of a large portion of patient care by singly qualified dentists. This care involves the prescription of medication and treatments that will in all likely hood be unfamiliar to a new dental core trainee which can be a daunting prospect (for both patient and supervising clinicians!). The purpose of this service evaluation is to assess the provision of care against clinical standards for record keeping set interdepartmentally and across Sheffield Teaching Hospitals (Based on established national guidelines set out by the Department of Health, WHO and NICE).