SECTION 4 (Clinical Audit) - The Somerset Local Dental ...



SOUTH WEST CLINICAL AUDIT AND PEER REVIEW ASSESSMENT PANEL

Dental Clinical Audit

3. Keeping of Patient Clinical Records

CAP Ref:      

Audit start date:        

Completion date:        

Panel member contact: Stuart Chadwick email - stuart.chadwick@

|Dental Clinical Audit report (tick) check list: |

|All sections need to be completed and included when returning your report: |

|1. Completed data capture sheets for cycle 1 & 2 pages: 5&6 | |

|2. Completed audit cycle one and two results and | |

|percentage results page:7 | |

|3. NHS England Area Team Mandatory Aims & Objectives page:8 | |

| | |

|3.1 NHS England Area Team Mandatory Action Plan page:8 | |

|3.2 NHS England Area Team Mandatory Feedback page:8 | |

|(how useful you found the audit) | |

|4. Declaration Tick confirmation box and Date page:9 | |

| | |

Please note –when returning your audit do not include any Dentist, Practice or patient demographic details.

2013 Structured Dental Clinical Audit on the 3.Keeping of Patient Clinical Records prepared by:

Prepared by: South West Clinical Audit & Peer Review Assessment Panel,

South West Commissioning Support (SWCS), Mallard Court, Express Park, Bristol Road, Bridgwater, Somerset, TA6 4RN.

South West Clinical Audit and Peer Review Assessment Panel

CLINICAL AUDIT FOR GDS/PDS DENTAL PRACTITIONERS

3. AUDIT OF KEEPING PATIENTS CLINICAL RECORDS

AIMS AND OBJECTIVES

• To highlight weaknesses in past record keeping

• To ensure future records contain all relevant information.

• To ensure the same quality of examination for each patient

• To help reduce litigation

The results of your audit will be recorded by the Panel who will feedback the overall findings for the area to yourself and the NHS England Area Team in an anonymous form. This will enable the NHS England Area Team to identify any areas that need support and enable you to compare your results with those of your local colleagues. Please return the results sheets and completed NHS England Area Team mandatory page to the Panel within three months.

Source material

Defence Union information

NICE - guidelines on examination frequency based on past caries and periodontic disease history

and Medical conditions, on the internet at .uk

SAMS

BDA - on the internet at

Health Protection Agency (formally NRPB) – reasons and frequency of X-rays

IR(ME)R

A suggested standard is as follows:

80% 0 items missing

10% 1 item missing

5% 2 items missing

5% 3+ items missing

If more than one dentist in the same practice completes the same audit, each dentist must complete their individual audit, data and feedback sheets.

METHOD

The audit will include 2 cycles: Retrospective and Prospective cycle.

SAMPLE SIZE OF 30 OF YOUR DENTATE ADULT (OVER 18) RECORDS RANDOMLY SELECTED TO FORM THE RETROSPECTIVE AUDIT.

Use Data collection sheets to investigate the following areas of record keeping: -

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South West Clinical Audit and Peer Review Assessment Panel

3. Keeping of Patient Clinical Records

Complete the Data Capture sheets (Y = Yes, N = No, N/A= Not applicable) where applicable using the following explanatory notes: Some of the areas also have Advisory parts to them which you can use in the audit or not. If you feel any of the areas below are not relevant to you, please amend and indicate when returning your completed audit or email stuart.chadwick@blueyonder.co.uk

|1. Name, Address etc |Name, address post code and date of birth. |

| |Advisory :- Guardian Details, Emergency contact details telephone number. |

|2. Medical History |Medical History, these should be a paper record signed and dated by the patient and dentist. Paper record should be |

| |amended if any changes made and resigned. |

|3. Soft Tissues |Should be recorded for all ages at every examination (including urgent) also to include external and internal record even |

| |if no findings. |

|4.Patient Information |To record smoking/use of tobacco products, alcohol intake, past dental history/attendance pattern Advisory: - Behavioural,|

| |diet, family history of gum disease. |

|5. Dental Charting |Full baseline charting of teeth and restorations, Charting of treatment proposed and provided. |

| |Advisory: - Base line charting on each record card. |

|6. Perio Charting |BPE charting initially and annually or recall, and where appropriate full 6 point charting. Children not necessary until |

| |7’s erupt. |

|7. Radiographs |Frequency, justification of radiograph, evaluation of findings and possibly quality assessment of the radiographs. |

|8. Symptoms diagnosis |Treatment date, any problems, diagnosis, investigations, evaluations, materials used, and drugs used. Patient symptoms, |

| |tests done record positive and negative findings. Record the diagnosis. |

|9. Treatment plans |Details of conversations with patients where appropriate should be signed and a copy kept with notes. Treatment options ad|

| |what treatment to be done. Where necessary a paper copy provided i.e. FP17DC for NHS. |

|10. Treatment |Tooth notation, treatment provided, materials used and any further treatment that may be needed. |

| |Advisory:- LA if used, batch numbers, expiry date, amount. As this is appearing on checklists by PCT’s and others. |

|11. LA used and |Prescriptions, justification, quantity, dosage and frequency. |

|Batch Number, |Custom made device sheets where necessary (Lab sheets). |

|Prescriptions, | |

|Custom devices | |

|12. Estimate and |Treatment Plans/Estimate where necessary, If electronically produced need to check with PCT that they are happy with this |

|Consent |format. |

|13. Payments |Payment from patient, recorded. |

|14. Recall Time |Suitable recall interval based on NICE guidelines. |

|Advice for Practices that are |The Blue acceptance forms (PR) do need to be kept for 2 years, the medical history sheet if possible to print off the |

|paperless |computer can be signed and signed treatment plans need to be kept. These can be kept in boxes in a separate area and a way|

| |devised to locate them when needed i.e. dated boxes. Where there is discussion on a contiguous course of treatment it may |

| |be possible to add this to the estimate which the patient signs. This last being the most important as most significant |

| |disputes are about money and if the patient has signed and you can produce a piece of paper you are in a much stronger |

| |position. These can also be scanned into the computer once signed and allocated to the patient's notes. |

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South West Clinical Audit and Peer Review Assessment Panel CAP Ref:      

3. Keeping of Patient Clinical Records Audit

Analyse results from 1st cycle and implement any changes. The effectiveness of these changes will be investigated by means of a prospective cycle. Collect data from 30 clinical records over a period of one month using the same formula as described in the retrospective audit.

Analyse your results and compare your results with the use of graphic representation.

This audit is useful to include the whole Dental team and could be started at a Practice meeting.

1. To do the retrospective audit, nominate one person to randomly choose 30 patients notes from a previous month for your patients. The Practice staff could check each card and/or computer record for the listed items and mark them on the data capture sheet.

2. When the first cycle is completed, at another practice meeting decide where the problems are and work out solutions and protocols to correct the problems.

3. After a month of using the new protocols, repeat the audit of another 30 record cards and/or computer records to see what improvement there has been.

4. Prepare your report, include the results from the first audit cycle including graphs and list any changes that were made before the 2nd audit cycle. The results of the 2nd audit should include figures and graphs comparing the 2 cycles.

5. List on the results page of your audit report how you have changed your practice, any further changes that may be needed and the benefit to the practice and the staff. Complete PCT mandatory page. Take a photocopy of final report for clinical governance file.

6. It is worth checking, if the Practice is computerised, that you can produce a hard copy of the clinical record if required.

Timetable of activity:

• Month one audit 30 retrospective records and analyse data, decide on changes

• Month two implement changes

• Month three audit 30 prospective records and analysis results and produce report

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South West Clinical Audit and Peer Review Assessment Panel CAP Ref:      

3. Keeping of Patient Clinical Records Audit

Cycle 1. Keeping of Patient Clinical Records Data Capture Sheet

|Complete form for each patient |

| |

|Y = Yes |

|N = No |

|N/A= Not applicable |

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South West Clinical Audit and Peer Review Assessment Panel CAP Ref:      

3. Keeping of Patient Clinical Records Audit

Cycle 2. Keeping of Patient Clinical Records Data Capture Sheet

|Complete form for each patient |

| |

|Y = Yes |

|N = No |

|N/A= Not applicable |

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South West Clinical Audit and Peer Review Assessment Panel CAP Ref:      

3. Keeping of Patient Clinical Records Audit

Results

|First Audit Cycle |

| |No. X |% = X x 100 /30 |

|0 items missing |      |      |

|1 item missing |      |      |

|2 items missing |      |      |

|3+ items missing |      |      |

|Second Audit Cycle |

| |No. X |% = X x 100 /30 |

|0 items missing |      |      |

|1 item missing |      |      |

|2 items missing |      |      |

|3+ items missing |      |      |

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NHS ENGLAND AREA TEAM MANDATORY PAGE CAP Ref:      

South West Clinical Audit and Peer Review Assessment Panel

3. Keeping of Patient Clinical Records Audit

Please complete this mandatory page as part of you Clinical Audit Activity, which will be sent anonymously to your NHS England Area Team.

|Keeping of Patient Clinical Records Audit feedback: |

|Were the following AIMS & OBJECTIVES ACHIEVED |Yes |No |

|To highlight weaknesses in past record keeping | | |

|To ensure future records contain all relevant information. | | |

|To ensure the same quality of examination for each patient | | |

|To help reduce litigation | | |

|Action Plan as a result of your Clinical Audit including any changes made between first and second audit cycles: |

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|How useful did you find this Dental Clinical Audit? |

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|Please tick one of the following: No use Useful Very Useful |

|Any comments on this Structured Dental Clinical Audit especially if you ticked no use: |

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For Panel use only:

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|Approved |Not Approved |

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South West Clinical Audit and Peer Review Assessment Panel CAP Ref:      

3. Keeping of Patient Clinical Records Audit

The results of your audit will be recorded by the Panel who will feedback the overall findings for the area to yourself and the NHS England Area Team in an anonymous form. This will enable the NHS England Area Team to identify any areas that need support and enable you to compare your results with those of your local colleagues.

Please return all the information in your report as detailed below within three months of the start date (If you would like longer than 3 months to complete your audit please contact Jackie).

|Dental Clinical Audit report check list |

|All sections need to be completed and included when returning your report: |

|1. Completed data capture sheets for cycle one and two (pages 5&6) |

|2. Completed audit cycle one and two results and percentage results (pages 7) |

|3. NHS England Area Team Mandatory page: Aims & Objectives |

|3.1 NHS England Area Team Mandatory page: Action Plan |

|3.2 NHS England Area Team Mandatory page: Feedback section |

|(how useful you found the audit) |

|4. Declaration Tick confirmation box and Date |

Please note: a copy of your completed Dental Clinical Audit should be retained by the practice as part of your practice clinical governance portfolio. Your NHS England Area Team may wish to examine your audit during any Clinical Governance practice inspections that may take place.

I confirm that I have completed the enclosed Dental Clinical Audit activity

Date:      

Please e-mail your completed Dental Clinical Audit to Jackie Derrick at: Dentalclinicalaudit@somerset.nhs.uk

*Permission to reproduce any of the South West Clinical Audit & Peer Review Assessment Panel Structured Dental Clinical Audits

will need to be obtained from the Panel.

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