Audit of dental record-keeping at a university dental hospital

dc.contributor.authorMoshaoa, Mpule Annah Lerato
dc.contributor.authorTaunyane, Keitumetse
dc.contributor.authorHlongwa, Phumzile
dc.contributor.emailmpule.moshaoa@up.ac.zaen_US
dc.date.accessioned2024-07-04T11:15:03Z
dc.date.available2024-07-04T11:15:03Z
dc.date.issued2023-12-20
dc.descriptionDATA AVAILABILITY : Data are available from the Human Research Ethics Committee (Medical) of the University of the Witwatersrand (contact via https://www.wits.ac.za/ethics/human-research-ethicscommittee- medical) for researchers who meet the criteria for access to confidential data.en_US
dc.description.abstractBACKGROUND : Good record-keeping is fundamental in clinical practice and essential for practising dental practitioners and those in training. AIM : This study aimed to evaluate the level of compliance with clinical record-keeping by undergraduate dental students and staff at a university dental hospital. SETTING : The selected study setting was the Admissions and Emergency section at a university dental hospital. METHODS : A retrospective, cross-sectional review was undertaken of 257 clinical records. The CRABEL scoring system was used to evaluate 12 variables. The 12 variables included: patient name, patient hospital number, date of examination, patient main complaint, medical history, dental history, proposed treatment, proposed procedure for next visit, patient consent signature, treatment and treatment codes, student name and signature, clinical supervisor name and signature. STATA® 13 was used for descriptive analysis and all tests were conducted at 5% significance level. RESULTS : The median CRABEL score was 87 and interquartile range (IQR: 70–92). A CRABEL score of 100 was achieved by the students in the variable patient main complaint, indicating a 100% compliance with this variable. Other variables such as signature of supervisors showed poor compliance. The CRABEL scores showed no statistically significant difference (p = 0.86) between the students and clinical supervisors. CONCLUSION : The overall audit showed that there was poor compliance with record-keeping. CONTRIBUTION : The study highlights the importance of good record keepings so that key information can be accessed for proper diagnosis and treatment of the patient. An electronic filing system presents an alternative manner of documenting medical records.en_US
dc.description.departmentOrthodonticsen_US
dc.description.librarianam2024en_US
dc.description.sdgSDG-03:Good heatlh and well-beingen_US
dc.description.urihttps://hsag.co.za/index.php/hsagen_US
dc.identifier.citationMoshaoa, M.A.L., Taunyane, K. & Hlongwa, P., 2023, ‘Audit of dental record-keeping at a university dental hospital’, Health SA Gesondheid 28(0), a2442. https://DOI.org/10.4102/hsag.v28i0.2442.en_US
dc.identifier.issn1025-9848 (print)
dc.identifier.issn2071-9736 (online)
dc.identifier.other10.4102/hsag.v28i0.2442
dc.identifier.urihttp://hdl.handle.net/2263/96799
dc.language.isoenen_US
dc.publisherAOSISen_US
dc.rights© 2023. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License.en_US
dc.subjectAuditen_US
dc.subjectRecord-keepingen_US
dc.subjectClinical dental recordsen_US
dc.subjectHospital recordsen_US
dc.subjectRecord auditen_US
dc.subjectSDG-03: Good health and well-beingen_US
dc.titleAudit of dental record-keeping at a university dental hospitalen_US
dc.typeArticleen_US

Files

Original bundle

Now showing 1 - 1 of 1
Loading...
Thumbnail Image
Name:
Moshaoa_Audit_2023.pdf
Size:
868.5 KB
Format:
Adobe Portable Document Format
Description:
Article

License bundle

Now showing 1 - 1 of 1
Loading...
Thumbnail Image
Name:
license.txt
Size:
1.71 KB
Format:
Item-specific license agreed upon to submission
Description: