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通过临床审计提高牙髓病记录的质量。

Improving the quality of endodontic record keeping through clinical audit.

作者信息

King E, Shekaran L, Muthukrishnan A

机构信息

Restorative Dentistry, Specialist in Special Care Dentistry and Oral Surgery; Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, SA6 6NL.

University of Warwick, Gibbet Hill Rd, Coventry, CV4 7AL.

出版信息

Br Dent J. 2017 Mar 10;222(5):373-380. doi: 10.1038/sj.bdj.2017.223.

Abstract

Introduction Record keeping is an essential part of day-to-day practice and plays an important role in treatment, audit and dento-legal procedures. Creating effective endodontic records is challenging due to the scope of information required for comprehensive notes. Two audits were performed to assess the standards of endodontic record keeping by dentists in a restorative dentistry department and students on an endodontic MSc course.Methods Fifty sets of departmental records and 10 sets of student records were retrospectively evaluated against the European Society of Endodontology 2006 guidelines. Results of the first cycle of both audits were presented to departmental staff and MSc students, alongside an educational session. Additionally, departmental guidelines, consent leaflets and endodontic record keeping forms were developed. Both audits were repeated using the same number of records, thus completing both audit cycles.Results The most commonly absent records included consent, anaesthetic details, rubber dam method, working length reference point, irrigation details and obturation technique. Almost all areas of record keeping improved following the second audit cycle, with some areas reaching 100% compliance when record keeping forms were used. Statistically significant improvements were seen in 24 of the 29 areas in the departmental audit and 14 of the 29 areas in the MSc audit (P = 0.05).Conclusions Significant improvements in endodontic record keeping can be achieved through the provision of education, departmental guidelines, consent leaflets and endodontic record keeping forms.

摘要

引言

记录保存是日常临床实践的重要组成部分,在治疗、审计和牙医学法律程序中发挥着重要作用。由于全面记录所需信息的范围,创建有效的牙髓病记录具有挑战性。进行了两项审计,以评估修复牙科部门的牙医和牙髓病理学硕士课程的学生在牙髓病记录保存方面的标准。

方法

根据欧洲牙髓病学会2006年指南,对50套科室记录和10套学生记录进行回顾性评估。两项审计的第一轮结果在一次教育会议上向科室工作人员和硕士研究生进行了汇报。此外,还制定了科室指南、同意书和牙髓病记录保存表格。使用相同数量的记录重复进行两项审计,从而完成了两个审计周期。

结果

最常缺失的记录包括同意书、麻醉细节、橡皮障使用方法、工作长度参考点、冲洗细节和充填技术。在第二个审计周期后,几乎所有记录保存领域都有所改善,当使用记录保存表格时,一些领域的合规率达到了100%。在科室审计的29个领域中有24个领域以及硕士审计的29个领域中有14个领域出现了具有统计学意义的改善(P = 0.05)。

结论

通过提供教育、科室指南、同意书和牙髓病记录保存表格,可以在牙髓病记录保存方面取得显著改善。

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