'Bytes and bites'--using computerized clinical records to improve patient safety in general dental practice.

UNLABELLED

Record-keeping is an essential part of clinical dental practice, having a direct relationship to patient safety and patient care. This study assesses the quality of record-keeping of 134 GDPs against 14 Clinical Governance standards. GDPs using computerized record systems showed statistically significantly (P < 0.05) better conformity for 11 of these standards than those using paper record systems. The use of computer records is therefore encouraged. In particular,the recording of medical history, soft tissues assessment, periodontal assessment and radiograph clinical evaluation is shown to be suboptimal and this could have potentially serious adverse effects on patient safety and patient care.

CLINICAL RELEVANCE

Improving the quality of clinical record-keeping will help to improve the quality of patient safety and patient care.