Record keeping by undergraduate dental students: a clinical audit

An audit was carried out to assess the standard of clinical record keeping by undergraduate dental students, with the object of improving the quality of care of patients treated by these students.

One hundred sets of undergraduate student clinical treatment records were evaluated against a modified CRABEL scoring system. The results of this initial part of the audit were presented in tutorial form to a group of 20 students, together with a teaching session on good record keeping, after which the audit was repeated, and another 100 records were examined over five consecutive Fridays, thus completing one complete audit cycle.

The most commonly absent record related to the department where the patient was seen followed by illegible signatures of both the demonstrator and the student. Almost all elements of record keeping investigated had improved in the second audit, most reaching 100% compliance, except for two (the updated medical history and the patient's most recent complaint).

Positive changes can be achieved by creating awareness among dental students on the importance of keeping records.