QUALITY OF RECORDS KEEPING BY UNDERGRADUATE DENTAL STUDENTS IN IBADAN, NIGERIA

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E.B. Dosumu¹, O.O. Dosumu² and F.B. Lawal³

1. Department of Periodontology and Community Dentistry, University College Hospital, Ibadan, Nigeria.
2. Department of Restorative Dentistry, University College Hospital, Ibadan, Nigeria
3. Department of Periodontology and Community Dentistry, University College Hospital, Ibadan, Nigeria

Abstract

Background: Recording the interaction between a patient and the dentist is of primary importance in dental practice. The completeness of recordings of undergraduate students, often inadequate, has been found to subsequently impact on the quality of dental care offered by professionals. Once identified, correcting the inadequacies has also been shown to improve the quality of dental practice.

Objective: We aimed to evaluate the quality of records keeping by dental students in Ibadan, Nigeria.

Method: A retrospective review of records of patients seen by dental students, at the clinics of the dental school in Ibadan, Nigeria, over a six months period was conducted. The charts were reviewed for: demographic data, medical and dental history, clinical findings, diagnosis, treatment plan and note on informed consent. Assessment of the quality of data obtained was done using a modified CRABEL’s scoring system.

Results: A total of 318 case files were retrieved for this study. The median modified CRABEL score was 95%, with a range of 65 to 95%. Eighty-two recordings (25.2%) had a score < 90%, while 236 recordings (74.2%) had a score > 90%. The most frequently unrecorded data was written consent in all the charts, followed by procedure done with the documentation absent in 20.4%. All the supervisors signed at the end of the consultation.

Conclusion: The quality of records keeping by dental undergraduates is fair but there is a need to emphasize deficient areas and improve upon the quality of record keeping.

Keywords: dental record, students, CRABEL score

Introduction

Dental record is a detailed and continuous documentation of the patient’s oral condition, contributing to diagnosis and orderly delivery of treatment to the patient^1,2 and it aids in the proper and adequate management of patients. The numerous functions of dental records have been widely documented and these include: use in research, administrative, financial, quality assurance, forensic and medico legal issues.^3,4 These functions are important and valuable to patient care, as good records help in assessing the quality of care while a poor one fails to. Previous studies have shown that dental records keeping are inadequate.^1,5,6 These inadequacies can however be assessed from the beginning, that is, while the dentists are still under training. This will form a part of assessment of the quality of training and even influence the way that undergraduate students are being taught and/or supervised in the clinics. Evidence has shown that records keeping among undergraduate dental students in the United Kingdom was far from optimal prior to when training was commenced.⁷ The resourcefulness of dental students during their training has been noted to impact on the eventual practice of dentistry.^8,9 Consequently, the quality of records keeping by students will be a predictor of future practice behaviour. Improvement of the quality of records keeping, after establishing a baseline degree of accuracy and quality, will lead to overall improvement in the care of dental services offered to communities.

It has however been observed that there is no documentation about clinical dental records keeping amongst undergraduate students in this part of the world. The aim of this study therefore is to assess dental records keeping amongst undergraduate dental students undergoing clinical training in Nigeria.

MATERIALS AND METHODS
A retrospective, descriptive study of the dental recordings carried out by undergraduate dental students between January 2006 and June 2006 at the Dental Centre, University College Hospital, Ibadan, Nigeria, was conducted. Ethical approval was obtained from the Institution’s Ethical Review Board.

The Dental Centre, University College Hospital, Ibadan is the teaching hospital arm of the Faculty of Dentistry of the University of Ibadan, Ibadan, Nigeria, the first University in Nigeria, the country with the largest population in Africa. Undergraduate dental students of the university rotate in their clinical years through the hospital, and participate in the active management of acute and chronic dental conditions, from the initial clerking of patients to formulating a treatment plan and carrying out this plan of action as well as followup of the patients.

The case files of the patients seen by dental students at the out-patient clinic of the dental centre of the hospital were reviewed over the six months period. The most recent entry in the case files was examined and information obtained on: date of documentation, demographic data, presenting complaint of the patient, past dental history, past medical history, and drug history. Others included: examination findings (of the patient), diagnosis, treatment plan, procedure done, signatures of the student and the supervising dentist, and indication of the department where the patient was seen.

The data retrieved was scored and rated using a modification of the CRABEL scoring system by CRAwford, BEresford and Lafferty.¹⁰ This scoring system was based on guidelines and principles of the Royal College of Surgeons for medical records usually for in-patients.¹¹ However, it was modified and used for the scoring in this study based on the basic requirements for dental records done through literature search.⁷ The CRABEL scoring system makes use of 100% from which deductions are made if any of the records are missing. The modified CRABEL scoring system used for this study is shown in Table 1. Data was computed using SPSS version 16 software. Results were presented as percentages and mean values used where appropriate.