Orthodontic Treatment Documentation by Postgraduate Students: A Comprehensive Audit and Peer Review

Complete and well-documented orthodontic records reflect clinician proficiency and ensure smooth care transitions, especially in educational settings.

This clinical audit evaluates the quality of orthodontic practice, focusing on documentation, attendance, emergency handling, and financial management at the orthodontic postgraduate clinic.

This clinical audit included 110 patients who completed their orthodontic treatment care under postgraduate students from April 2023 to June 2024. The audit checklist was adapted from the available standards and guidelines. The audit was divided into two parts: details of the tenth criteria for the examination and diagnosis (ED) form and six assessment attributes, namely, treatment progress records. The level of compliance was measured as the percentage of records meeting the criteria. The data were statistically analysed with SPSS.

Out of the records reviewed, 80 (72.7%) were found to be fully documented, although radiographic findings and supervisor signatures were frequently missing. Additionally, 64.5% of patients had non-attendance exceeding 8 weeks, which was strongly correlated with longer treatment times (r = 0.744, p < 0.01). A small proportion had multiple emergency appointments, but notably, no adverse events were reported. Treatment duration differed by IOTN (p = 0.003), with patients having an IOTN score of 5 experiencing the longest treatment duration. On average, patients completed their payments in 23.74 ± 14.24 months. The strengths of this audit included a structured checklist and actionable recommendations.

The clinical audit showed high compliance with ED form and treatment progress documentation, highlighting strengths, identifying gaps, and emphasizing accuracy, confidentiality, and improvement.