Abdul Rahman Izzatul Najwa, Khamis Mohd Fadhli, Mohd Rokemi Norhaslina
School of Dental Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, MYS.
Cureus. 2024 Feb 27;16(2):e55087. doi: 10.7759/cureus.55087. eCollection 2024 Feb.
Dental records are an essential part of dental practice. The quality of dental recordkeeping is paramount in ensuring the delivery of high-quality dental care and is also important for medico-legal reasons. Should there be any dispute or need for review, detailed and well-maintained records can provide evidence of the care provided and the decision-making process.
The study aimed to assess the quality of dental recordkeeping and dental charting practice at the dental clinic School of Dental Sciences.
The study was conducted in a retrospective manner reviewing dental records of patients treated by specialists, dental officers, and postgraduate and undergraduate students at the Hospital Universiti Sains Malaysia over a five-year period. Eight key components of clinical dental records . date of charting, legibility on the odontogram, no blank on the odontogram, whether any mistakes have been strikethrough and initials, medical history, dental history, investigation, and treatment plan were assessed. A modified CRABEL scoring system was used to assess the quality of data retrieved from dental records.
The study involved the analysis of 324 case files. Among these, 90 files obtained scores ranging from 60% to 80%, with 7.7% attributed to undergraduates, 9.6% to dental officers, 6.8% to postgraduates, and 3.7% to specialists. The remaining 234 files achieved scores between 80% and 100%, with a breakdown of 17% from undergraduates, 15.4% from dental officers, 18.2% from postgraduates, and 21.3% from specialists.
Even though the overall quality of recordkeeping in this study is good, with most records achieving a CRABEL score of 80% and above, it's important to acknowledge that ideally, each component assessed should achieve a perfect score of 100%, as it will reflect the practitioners's work.
牙科记录是牙科诊疗工作的重要组成部分。高质量的牙科记录保存对于确保提供优质的牙科护理至关重要，并且出于医疗法律原因也很重要。如果出现任何争议或需要复查，详细且保存良好的记录可以提供所提供护理及决策过程的证据。
本研究旨在评估牙科科学学院牙科诊所的牙科记录保存质量和牙图表绘制实践情况。
本研究采用回顾性方式，审查了马来西亚理科大学医院专科医生、牙科官员以及研究生和本科生在五年期间治疗的患者的牙科记录。评估了临床牙科记录的八个关键组成部分——绘图日期、牙图表上的易读性、牙图表上无空白、是否有任何错误被划掉并签名、病史、牙科病史、检查和治疗计划。使用改良的CRABEL评分系统评估从牙科记录中检索到的数据质量。
该研究涉及对324份病例档案的分析。其中，90份档案得分在60%至80%之间，本科生占7.7%，牙科官员占9.6%，研究生占6.8%，专科医生占3.7%。其余234份档案得分在80%至100%之间，本科生占17%，牙科官员占15.4%，研究生占18.2%，专科医生占21.3%。
尽管本研究中记录保存的总体质量良好，但有大多数记录的CRABEL得分在80%及以上，然而必须认识到，理想情况下，所评估的每个组成部分都应达到100%的满分，因为这将反映从业者的工作。
