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Audit of Record-keeping

stack of filesIn 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 the NHS Education for Scotland (NES) for further details.