In addition to facilitating quality patient care and providing a permanent record of the care of patients, well-kept dental records are an excellent source of information to help support evidence-based research in dentistry. Therefore, it is important to strive to improve the standard of record-keeping. One method of doing this is to conduct an ‘in-house’ audit using existing information contained in practice records.
Conduct audits of record-keeping based on, for example:
- personal details of patients for administration
- medical histories completed, dated and signed
- radiographs properly recorded and mounted
- periodontal screening documented
- oral cancer screening documented
- care plans recorded adequately
- children’s caries risk status recorded
- dates of proposed next bitewing radiographs recorded if applicable
- preventive measures noted.
Refer to Quality Improvement Activity for the principles of conducting an audit and refer to NHS Education for Scotland (NES) [1] for further details.