ClinicalPractice

Richard Spicer

Bytes and Bites Using Computerized Clinical Records to Improve Patient Safety in General Dental Practice
Abstract: Record-keeping is an essential part of clinical dental practice, having a direct relationship to patient safety and patient care. This study assesses the quality of record-keeping of 134 GDPs against 14 Clinical Governance standards. GDPs using computerized record systems showed statistically significantly (P < 0.05) better conformity for 11 of these standards than those using paper record systems. The use of computer records is therefore encouraged. In particular, the recording of medical history, soft tissues assessment, periodontal assessment and radiograph clinical evaluation is shown to be suboptimal and this could have potentially serious adverse effects on patient safety and patient care. Clinical Relevance: Improving the quality of clinical record-keeping will help to improve the quality of patient safety and patient care. Dent Update 2008; 35: 614-619 Keeping good clinical dental records is a vital part of dental practice.1 The General Dental Council (GDC) has recently published ethical guidance for its registrants Ethical Guidance Standards for Dental Professionals which specifically mentions keeping good and accurate clinical records in two of its six key principles.2 Records should be legible, accurate, comprehensive and contemporaneous.3 Each patient should have an individual dental record.4 Four reasons for keeping clinical records are: As an official document/record of events; To facilitate the process of dental audit; To monitor the patients state of oral health; To aid the process of forensic odontology.5 Additionally, good records can act as a defence in medico-legal cases against claims of professional misconduct or clinical negligence.1,6 There are relatively few published studies on the quality of dental clinical record-keeping in the United Kingdom. A study of 464 records of 47 General Dental Practitioners (GDPs) in England and Wales found that their standard of clinical record-keeping was poor.7 Another study, comparing their dental charting of teeth present in 200 patients with the charting information provided by the referring dentist, found 52% of the cases to have been charted incorrectly.8 Assessments involving dentists working in private (Denplan scheme) practice and undergraduate dental students also indicated poor standards of recordkeeping.5,9 These studies were audits involving one complete cycle, with an accreditation programme underpinning the former study, and with tuition being given on good record-keeping in the latter study. Encouragingly, significant improvements were seen in the subsequent assessments of the quality of record-keeping by the dentists in both studies. In a postal self-completion questionnaire survey of 800 GDPs, regarding the use of the Basic Periodontal Examination (BPE) to assess periodontal disease, conformity of 56% was reported.10 The quality of clinical dental record-keeping also impacts on patient safety. No reference linking the quality of clinical records and patient safety was found from a literature search using these terms. This study explores the potential adverse effects of poor quality recordkeeping on patient safety. The Health and Social Care Act (2003) charged the Primary Care Trusts (PCTs) in England with a duty to monitor and improve the quality of the services that they commission or provide continuously. The activities of the Dental Reference Officers (DROs) of the NHS Business Services Authority aim to support that duty by being involved with Dental Clinical Governance and by giving clinical quality support to PCTs and dentists. November 2008

Richard Spicer, BDS, BSc, MFGDP(UK), MMedEd, Dental Reference Officer, Dental Services Division, NHS Business Services Authority and Postgraduate Clinical Dental Tutor, Coventry, UK.

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Clinical Record Criteria Patient Identifiers (name, date of birth, address and telephone number)1,3,11 Medical History1,3,11 Dental Charting1,3,11,16 Periodontal Assessment
11,16

Radiograph Criteria Prescription (appropriate view, frequency and justification)1,9,14,15 Evaluation1,15 Quality14 Administration (date and patients name)
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storing patients clinical records and 24% for storing digital radiographs. Thus the use of computers in general practice appears to be increasing. The study compares paper and computerized record systems with regard to the quality of clinical dental record-keeping.

Method
The study analysed the clinical records of 134 randomly-selected dentists contracted under the NHS Personal Dental Services to five different PCTs in the Midlands (of England) with the majority working under three of the PCTs. Eight records were analysed for each dentist, four selected by the dentist and four randomly selected by the DRO in visits conducted in 2005 and 2006. The GDPs were given several weeks advance notice of the DRO visit and informed that a CRR would be undertaken. The author was present for all bar 11 of the CRRs; another DRO, who was calibrated with the author, was present for these 11 CRRs. Each record was systematically analysed following a template corresponding to the criteria listed in Table 1 and conformity or not to the Clinical Governance standards and good practice noted. The findings were discussed with the GDP in a verbal feedback session during the visit. Data were collected on individual patients during the DRO visits and then collated in a database. Individual patients cannot be identified from the database. Statistical analyses of the results using chi-squared tests on pairs of variables, with one degree of freedom, were carried out. Values of P < 0.05 were considered to be significant. The clinical dental record systems used in the sample practices were classified as either PAPER or COMPUTER, depending on how the notes of the treatment provided were recorded.

Soft Tissues Examination1,3,11,16 Patient Information (previous dental history, social history and symptoms)1,3 Treatment Planning1,3,11 Treatment Provided1,3,11,16 Recall Interval12,13 Administration (NHS documents FP17PR form, FP17DC - referral letters, laboratory dockets)1,3,11,12
Table 1. List of criteria assessed in a DRO visit for a CRR.

Type of Number of Performers Number of Clinical Number of Cases Clinical Records (% sample) Records with Radiographs TOTAL Paper Computer
Table 2. Sample sizes.

134 70 (52.2%) 64 (47.8%)

1072 560 512

856 425 431

A Clinical Governance framework for Primary Dental Care in England has recently been published (NHS Primary Care Contracting, 2006). This framework has 12 themes, including clinical records, dental radiography, clinical audit and peer review. The visit by the DRO to the NHS dental practice gathers information about dentists and their practices in an objective way. A clinical records review (CRR) is included for each dentist, in which 14 criteria (listed in Table 1) are assessed in each of 8 cases for conformity to national Clinical Governance standards and good practice. The first 10 of these criteria relate to clinical dental records and the remaining November 2008

4 criteria relate specifically to radiographs. This paper reports on the results of the CRRs of a sample of GDPs. A survey of 5000 practices across the United Kingdom in 1997 found that 59% had computing facilities.17 Another study, of 183 dentists in Glasgow, reported that only 21% had practice computers.18 This compared unfavourably with 213 doctors in the same study, 85% of whom had practice computers. More recently, a study of 356 practices in the Thames Valley Strategic Health Authority Region showed that 77% of these practices were using, or planning to use, computerized systems.19 Of the practices, 74% used their system for transmitting payment data, 59% for

Outcomes and results

Clinical records total sample

A total of 1072 clinical records were analysed in the study, 512 computer and 560 paper Table 2. Table 3 shows the percentage conformity to the Clinical Governance standards of all the DentalUpdate 615

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Criterion

Conformity Total Records (%) (n=1072) 95.0 68.2 95.4

Criterion

Conformity Total Records (%) (n=856) 53.9 60.7 92.6 68.0 68.8

Patient Identifiers Medical History Dental Charting

Prescription Evaluation Quality Administration OVERALL

dental charting, patient information and treatment planning showed high levels of conformity. Periodontal assessment, treatment provided and recall intervals formed the moderate group. Three criteria soft tissue examination 72.2%; medical history 68.2%; administration 52.0% made up the low conformity group.
Radiographs total sample

Periodontal Assessment 85.2 Soft Tissue Examination 72.2 Patient Information Treatment Planning Treatment Provided Recall Intervals Administration OVERALL 96.3 92.1 80.1 85.4 52.0 82.2

Table 4. Total radiographs % conformity to Clinical Governance standards.

Table 3. Total records % conformity to Clinical Governance standards.

assessed clinical records. For the 10 criteria in the 1072 records, an overall mean conformity of 82.2% was recorded. The results for the individual criteria fall into three groups high (defined as > 90%), moderate (8090%) and low (< 80%) conformity. Four criteria patient identifiers,

Criterion

% conformity Computer Records (n=512) 96.9 76.2 97.7 85.4 78.9 97.7 94.1 84.8 96.1 60.0 86.8

% conformity Paper Records (n=560) 93.3 60.9 93.4 85.0 66.1 95.0 90.2 75.9 75.5 44.6 78.0

Significance

Patient Identifiers Medical History Dental Charting Periodontal Assessment Soft Tissue Examination Patient Information Treatment Planning Treatment Provided Recall Intervals Administration OVERALL

<0.01 <0.001 <0.01 NOT <0.001 <0.05 <0.05 <0.001 <0.001 <0.001 <0.001

Of the clinical records, 856 (79.9%) had one or more associated radiograph(s) taken by the dentist in the previous two years Table 2. The total number of radiographs is not recorded as part of the DRO visit process, only the number of records that have one or more associated radiograph(s). However, the number of radiographs assessed for a subset of 89 dentists in the total sample was recorded 1347. Of these radiographs, 47 (3.5%) were graded unacceptable. Dentists with access to digital radiography facilities numbered 12 (9.0%). Table 4 shows the percentage conformity to the Clinical Governance standards of all the assessed radiographs. For the four radiography criteria, an overall mean conformity of 68.8% was recorded. The results for the individual criteria fall into 2 groups high (> 90%) and low (< 80%) conformity. The quality of the radiographs was high, scoring 92.6% conformity, whilst the other three criteria assessed showed low levels of conformity.
Clinical dental records computer versus paper

For 9 of the 10 criteria assessed and overall the computer records showed a statistically significantly better conformity to the Clinical Governance standards than the paper records Table 5. For the other criterion, periodontal assessment, no significant difference was found between the computer and paper record samples.
Radiographs computer versus paper

Table 5. Computer versus paper clinical records % conformity to Clinical Governance standards.

For two of the four radiography criteria assessed prescription and November 2008

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Criterion

% Conformity Computer Records (n=431) 57.5 63.8 91.0 79.1 72.9

% Conformity Paper Records (n=425) 50.1 57.6 94.4 56.7 64.7

Significance

Prescription Evaluation Quality Administration OVERALL

<0.05 NOT NOT <0.001 <0.001

Table 6. Computer versus paper radiograph records % conformity to Clinical Governance standards.

administration and overall the computer records showed statistically significantly better conformities to the Clinical Governance radiography standards than the paper records Table 6. For the other two criteria, evaluation and quality, no statistically significant differences were found between the computer and paper record samples.

Discussion
Clinical records

There is no standard dataset for dental clinical records.1 However, there are elements whose inclusion is indicated by good practice or guidelines and those required by Statutory Regulations or other Legislation. Four criteria patient identifiers, dental charting, patient information and treatment planning were recorded to a high standard by the dentists assessed. Periodontal assessment, treatment provided and recall intervals were recorded to a more moderate standard. The levels of conformity for soft tissue examination, medical history and administration of 72.2%, 68.2% and 52.0%, respectively are of concern, having the potential for significant adverse effects on patient safety. Two studies,5,7 assessing the recording of medical history and treatment plans, reported lower levels of conformity than this study, and one9 showed similar levels. Two of these studies5,7 also measured the recording of soft tissue assessments, finding levels much lower than this study.

Two studies have been published on the recording of dental charting,7,8 both showing lower levels than this study. One of these studies measured the presence and accuracy of the charting and found only 48% conformity. This suggests that, if the corresponding patients had been examined in this study, the conformity for dental charting may have been lower than the recorded 95.4%. Two studies recorded the presence of periodontal screening, finding much lower levels than this study.5,7 A survey of periodontal screening recording (published 2004), using a self-completion questionnaire mailed to 800 NHS GDPs in England and Wales, reported conformity of 56.0% for all patients.10 This type of survey depends on the honesty of the dentists when completing the questionnaire. In this respect, a recent study suggests that the perceptions of dentists of their recording of their treatment practices exceed that found in the actual patient documents.20

19941999) had shown much lower levels of quality of dental radiographs taken by GDPs.23,24,25 These results suggest that the quality of dental radiography has improved markedly this century and, whilst further improvements could be made, it is not a primary concern at present. The writing of a clinical evaluation for each radiographic exposure is a specific requirement of IR(ME)R (2000).15 No studies assessing compliance with this requirement were apparent in the literature searches. Of the clinical records in this study, 4 in 10 did not comply with this requirement. This has potentially adverse effects on patient safety. Overall, the radiograph criteria assessed in this study showed low conformity to Clinical Governance standards.
Computer versus paper records

In this study, dentists using computer records adhered to the majority of the Clinical Governance standards assessed statistically significantly better than those using paper records. The main reasons apparent were the use of custom screens and pop-up notes on the computer, saving considerable time in entering data and providing reminders of important information, respectively. Of the 48 dental practices studied in the project, 18 (37.5%) used a computerized record system. A questionnaire-based study of 313 practices (published 2003) reported 59% storing records on a computer.19 No studies have been published comparing the two types of clinical dental record systems.
Implications for clinical practice

Radiographs

Computerization

Of 1347 radiographs, 96.5% showed satisfactory quality or better; 3.5% were unacceptable. The National Radiological Protection Board has published Guidelines on the subjective quality rating of radiographs.21 The minimum target recommended for unacceptable radiographs was not greater than 10% of a representative sample. A recent study analysing the quality of 400 bitewing radiographs found 5.2% to be unacceptable.22 Previous studies (published

This study indicates that, from the viewpoint of record-keeping, the development of positive attitudes towards computerization by dentists and their practice teams should be encouraged to help improve standards of Clinical Governance and patient safety.
Patient safety

The literature does not specifically mention patient safety as a reason for keeping good clinical dental November 2008

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records. However, a crucial aspect of recordkeeping is its relationship to patient safety. Poor record-keeping has an adverse impact on patient safety as essential information is incomplete or incorrect. The standards found for the recording of medical history, and soft tissue examination in particular, have potentially serious adverse effects on patient safety, including an adverse medical event and missed oral cancer, respectively. Appropriate educational interventions, including training sessions, on dental record-keeping for individual dentists, individual dental practices and groups of dental practices are indicated.

the NHS Business Services Authority (BSA) for kindly allowing the use of the data. The comments made in the discussion, conclusions and recommendations are my own personal interpretation of the data.

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References
1. 2. DCruz L. Off the record. Dent Update 2006; 33: 390400. General Dental Council. Ethical Guidance Standards for Dental Professionals 2006. www.gdc-uk.org/Current+registrant/ Ethical+guidance Faculty of General Dental Practitioners (UK). Clinical Examination and RecordKeeping Good Practice Guidelines. Pitts NB, Pendlebury ME, Clarkson JE, eds. London: Faculty of General Dental Practitioners (UK), 2001. American Academy of Paediatric Dentistry Clinical Guidelines on Recordkeeping. Paediatric Dentistry 2004; 26: 134139. Ireland RS, Harris RV, Pealing R. Clinical record keeping by general dental practitioners piloting the Denplan Excel Accreditation Programme. Br Dent J 2001; 191: 260263. Brands WG. The standard for the duty to inform patients about risks: from the responsible dentist to the reasonable patient. Br Dent J 2006; 201: 207210. Morgan RG. Quality evaluation of clinical records of a group of general dental practitioners entering a quality assurance programme. Br Dent J 2001; 191: 436441. Platt M, Yewe-Dyer M. How accurate is your charting? Dent Update 1995; 22: 374. Pessian F, Beckett HA. Record keeping by undergraduate dental students: a clinical audit. Br Dent J 2004; 197: 703705. Tugnait A, Clerehugh V, Hirschmann PN. Use of the basic periodontal examination and radiographs in the assessment of periodontal diseases in general dental practice. J Dentistry 2004; 32: 1725. Faculty of General Dental Practitioners (UK). Current Guidance for General Dental Practice. London: Faculty of General Dental Practitioners (UK), 2004. Statutory Instrument No. 3373. The National Health Service (Personal Dental Services Agreements) Regulations 2005. www.opsi.gov.uk/si/si2005/20053373. htm National Institute for Clinical 15.

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Conclusions and recommendations

The overall quality of the clinical dental records assessed in the study was moderate. Recall intervals, treatment provided and periodontal assessments were recorded to a moderate standard. Further education on these topics is recommended for dentists and their practice teams. Soft tissue examinations, medical histories and administration, together with radiograph prescription, evaluation and administration were recorded to a low standard. Appropriate training of the dentists and their practice teams is recommended to meet these identified educational needs. The quality of the radiographs was good. Further education on radiograph quality is not currently a priority. Computer records rated significantly better than paper records for 11 of the 14 criteria assessed. These are important findings, given the potential adverse effects on patient safety of poor record-keeping. Pre-set computer custom screens and pop-up notes prompt the dentist with important information and reminders. Computer records use should be promoted. Digital radiography was only used by a small number of the dentists in the study but would appear to have a significant advantage for patient safety in the reduced radiation dose to the patient used compared to conventional dental radiography.
Acknowledgements

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I am grateful to Alison Bullock, Jane Kidd and Colin Ritchie for their help and The Dental Services Division (DSD) of November 2008

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