Presentations 2020: OMFS

392 - Keeping the record straight: An audit on record keeping in Oral & Maxillofacial Surgery.

L Price L Chen A Goodson MH Tahir
Presented by: Hassan Tahir
Cardiff Dental Hospital

Introduction Accurate medical records are a vital pillar of patient safety as they are a basis of communication between healthcare professionals. Accurate and up to date records are a necessity for auditing, research and medico-legal purposes. The Royal College of Surgeons state in Good Surgical Practice that surgeons should ‘Ensure that all medical records are accurate, clear, legible, comprehensive and contemporaneous and have the patient’s identification details on them’. Aim: Improve the standard of record keeping for new patients referred to OMFS Consultant Outpatient Clinics. Objectives: To ensure the standard of record keeping for new patients meets Departmental Guidelines To ensure there is no difference between the standard of record keeping for doctors of varying grades: Dental Core Trainees (DCT), Core Surgical Trainees (CST), Registrars (Reg) and Consultants. Audit Standards: Achieve an overall target of 80% compliance with local OMFS Departmental Guidelines on record keeping for new patients referred to OMFS Consultant Outpatients Clinics. Method: Retrospective analysis of 26 new patients from all OMFS Consultant outpatient clinics in December 2018 was performed. Data was collected on the proforma designed with respect to the local departmental note keeping guidelines and points awarded for each category. Following the first cycle, the guidelines were sent to all OMFS doctors in March 2019 and permanently displayed in outpatient clinics. The second cycle data was collected on 27 new patients in July 2019. Results: Cycle 1: DCT (90%), CST (81%), REG (83%), Consultant (70%). Overall Compliance was 81% Cycle 2: DCT (91%), CST (88%), REG (87%), Consultant (80%). Overall Compliance was 87% Conclusion Overall compliance increased from 81% to 87% Compliance increased for doctors of all grades Consultants achieved minimal target of 80% compliance during re-audit Teaching session on record keeping guidelines for new doctors at induction
Consent Statement: There are no details on individual patients reported within the abstract.

Poster