Abstract

Objective: To assess results of clinical audit of quality of record keeping, for procedures in accordance with international standards.
Methodology: This study was conducted at the Oral & Maxillofacial Surgery Department of the University Dental Hospital. We selected 150 handwritten medical records for audit using a modified CRABEL score, which consists of 10 variables with a maximum score of 100.
Results: The legibility of the records was commendable at 92%. In 66% cases, there was no mention of the patient’s chief complaint and in 44%, a diagnosis was not documented before recommending extraction. These findings highlight negligence in mentioning patient complaints and establishing diagnoses before performing extractions. An informed consent was obtained in 96% of cases prior to the procedure.
Conclusion: Although the legibility is deemed satisfactory there were deficiencies in documenting patients’ chief complaints and formulating pre-extraction diagnoses. To tackle these challenges, we suggest implementing focused interventions like workshops and lectures on record-keeping awareness at the beginning of each rotation. These educational initiatives can help bridge any existing gaps leading to compliance with standards and ensuring more thorough documentation of patient care.

Key words: Clinical audit, exodontia, CRABEL score, record keeping, clinical notes.