2021 11 17

A clinical audit to investigate the impact of COVID-19 on record-keeping in dental undergraduate restorative clinics

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Ishita Aswa (MSc - Dissertation), Ali Nankali (Supervisor)

Clinical dental records that are accurate and complete have the potential to be used for a variety of significant purposes, mainly for improving patient safety and treatment quality, but additionally acting as good evidence in litigatory cases. This audit was aimed at assessing the standard of record-keeping by undergraduate dental students attending restorative clinics at the Royal London Dental Hospital. The secondary aim of this project was to delineate any differences in recordkeeping quality that the COVID-19 pandemic might have caused.

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Methodology:
The audit compared two types of records, 45 paper-based records that were used before the coronavirus outbreak and 45 digital records used in the hospital since the pandemic. The quality was evaluated by assessing records for completeness of certain ‘gold standard’ entries/domains as per the United Kingdom national guidelines. Each record was scored for the presence or absence of 10 ‘domains’, which were further divided into 32 ‘components’. Total scores and percentages of entries for each component were calculated in the records before and during the COVID-19 pandemic to find a difference.

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Results:
Overall record-keeping by undergraduates fell evidently short of standards, even though 9 out of the 10 domains improved in completeness since the pandemic. Various problems seemed to arise with the paper records such as illegible handwriting, missing papers and inconvenience with storage and retrieval of files. Radiographic reporting improved greatly since the pandemic, whereas dental history recording was even lower than before.

Conclusions:
An overall failure to record basic components by undergraduates in the records was found. This is a critical issue in health care delivery; thus, awareness should be incorporated into the dental curriculum without delay. This study supports the use of clinical audit for quality assessment and improvement of dental records. Furthermore, innovative teaching and feedback-learning methods can prove to be extremely useful.

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