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Clinical audit tools

Exercises in risk management

The following short articles were originally published in Riskwise. Addressing some of the most problematic areas of clinical record keeping, these audit tools offer a practical method for reviewing the quality of your clinical records. 

Each article provides a clinical audit tool for an area of clinical record keeping which commonly gives rise to problems. In each case, a practical audit framework is suggested, for use when reviewing the clinical records being kept for these different aspects of clinical activity.

  • Communications between dentists and technicians
    Dentists communicate with their technicians (and vice versa) in a variety of ways, and on a variety of subjects. Yet in the experience of Dental Protection, many valuable opportunities to improve the quality of these communications seem to be missed. Although there has to have been some dialogue, there is often little or no tangible evidence that this was so.
    26 August 2014
  • Co-operation & compliance
    There are many examples in clinical dentistry, of treatment which is largely dependent upon the level of co-operation from the patient, and/or the degree to which the patient follows the advice and recommendations of the clinical team.
    27 August 2014
  • Follow-up arrangements
    There are many moments in clinical dentistry when the most crucial aspect of case management is not what you do, but what arrangements you make to monitor the effectiveness of what you do.
    27 August 2014
  • Monitoring early caries
    New techniques, new materials and perhaps more importantly, a shift in treatment philosophies in recent years has led to a greater emphasis upon minimally interventive, preventive approaches to the management of the early carious lesion. In some key respects new technology has helped, and in other respects it has hindered, this process.
    27 August 2014
  • Patient information
    In case after case, the question arises of what information a patient was given in advance of their treatment. Obviously, this is material to the quality of the consent obtained from the patient, and yet dentists, hygienists and therapists often find themselves unable to demonstrate with any certainty, exactly what the patient was told, when, and in what terms
    27 August 2014
  • Periodontal monitoring
    Undiagnosed and untreated periodontal disease is one of the fastest growing areas of litigation and complaints in dentistry.
    27 August 2014
  • Post-operative instructions
    Busy clinical teams often say that there is never enough time to apply all the risk management advice they are given. This series distils the key messages from a specific area of risk to provide some practical tools that can make a real difference right away.
    27 August 2014
  • Recording pain
    Patients are often prompted to visit the dentist because they have been experiencing pain or discomfort. Recording the details of the pain (as described by the patient) in a structured, detailed fashion is an important aspect of clinical record keeping and can be invaluable in assisting the clinician to reach an appropriate diagnosis and treatment plan, and in monitoring treatment outcomes.
    27 August 2014
  • Risk factors
    A clinician’s specialised knowledge of the aetiology of various oral and dental conditions places him, or her, in a position of significant advantage relative to most patients. That said, the role of oral hygiene in various dental conditions, and the role of diet in caries are, in broad terms at least, well known to most patients, even if they are not acted upon.
    27 August 2014
  • Soft tissues
    Unlike many other areas of healthcare, dentists generally get to examine fit ambulant patients at varying intervals, and at times when they may have no symptoms or any particular reason for attending, other than for a periodic review of their oral health. This provides dentists, dental hygienists, dental therapists and clinical dental technicians with an almost unique opportunity that is not shared by many of their colleagues working elsewhere in healthcare.
    27 August 2014
  • Tooth surface loss
    Not only is the prevalence of tooth surface loss (TSL) increasing, but clinicians increasingly find themselves facing criticism and challenges regarding its diagnosis and management. A clinician’s failure to investigate TSL adequately, perhaps leading to an incorrect diagnosis and inappropriate treatment (especially, where such treatment is unnecessarily interventive) are the most common problem areas encountered.
    27 August 2014