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Abstract An audit was conducted at Hamdard University Dental Hospital to assess the standard of clinical record keeping by undergraduate dental students, house officers and faculty members. Objective of this audit was to improve the quality of care of patients treated by the staff and students.
100 hospital notes were audited for this purpose. These records were randomly selected from the record room at HUDH. CRABEL score was used for assessing the quality of these notes.
Ten variables were measured in our study. Data analysis was done on SPSS version 16. Descriptive statistics were performed. Mean CRABEL score was found to be 50.
94% of the notes had readable writing. 87% of the clinical notes did not mention the chief complaint of the patient.98% of the clinical notes had no mention of consent in them, while 43% of the clinical notes did not mention the investigations performed. These inferences clearly suggest that the current standards of clinical notes need considerable improvements. Further studies are planned in the future after addressing the present deficiencies.
Key Words: Dental record keeping, CRABEL score, Clinical audit, Medical records, History taking, Consent.
INTRODUCTION A dental record refers to the documents related to the history of present illness, clinical examination, diagnosis, treatment done and prognosis.1 Record keeping has always been a fundamental requirement in healthcare.2 According to Platt in 1947, a proper diagnosis depends upon three pillars, a strong medical history, signs and symptoms and laboratory investigations. Proper record keeping has been emphasized as a professional3 as well as a legal obligation.4 Medical and dental schools play a key role in developing a habit of record keeping among the future practitioners.5 The record keeping helps the practitioner in devising a proper treatment plan and prevents loss of valuable information regarding patient's illness and treatment. It also prevents confusion regarding patient's illness and treatment even if it involves multiple visits or multiple operators. The adequacy of treatment plan can be evaluated at any time for professional as well as medicolegal reasons. It is a dilemma that although dental records can also be used for and have an important role in teaching and in research6, a proper history taking and record keeping has always been ignored especially in dental schools and colleges....