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Orthodontic Treatment Documentation by Postgraduate Students: A Comprehensive Audit and Peer Review
Xin Yi Tan1, Kim Lian Lau1, Jeannette Dino1
1Faculty of Dentistry, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
Summary
This orthodontic clinical audit found 72.7% of patient records were fully documented, but often missed radiographic findings and supervisor signatures. Gaps in documentation and long patient absences impacted treatment times, indicating areas for practice improvement.
Area of Science:
- Orthodontics
- Dental Public Health
- Clinical Audit
Background:
- Complete orthodontic records are crucial for clinician proficiency and patient care transitions.
- Educational settings require robust documentation for training and quality assurance.
Purpose of the Study:
- To evaluate the quality of orthodontic practice at a postgraduate clinic.
- Focus areas included documentation, patient attendance, emergency management, and financial aspects.
Main Methods:
- A clinical audit of 110 patients treated by postgraduate students (April 2023 - June 2024).
- Utilized an adapted audit checklist focusing on examination and diagnosis forms and treatment progress records.
- Compliance measured by percentage of records meeting criteria; data analyzed statistically.
Main Results:
- 72.7% of records were fully documented; common omissions included radiographic findings and supervisor signatures.
- 64.5% of patients had prolonged absences (>8 weeks), correlating with longer treatment durations (r=0.744, p<0.01).
- Treatment duration varied by Index of Orthodontic Treatment Need (IOTN), with IOTN 5 cases taking longest; no adverse events reported.
Conclusions:
- High compliance observed for examination/diagnosis forms and treatment progress documentation.
- Identified specific documentation gaps and areas for improvement in orthodontic practice.
- Emphasized the importance of accuracy, confidentiality, and continuous quality improvement in postgraduate orthodontic training.
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