Following
a practice meeting it was decided to undertake an audit on the accessibility of
information from four key areas within the notes that were deemed to be
important, namely:
1. The
correct ordering of the FP25 cards within the notes so treatment previously
carried out on a patient could easily be followed chronologically over time.
2. The
medical history being clearly recorded (including the date when it was last
updated).
3. The
BPE was being clearly recorded at the correct time intervals.
4. Radiographs
easily found within the notes and correctly named dated and area radiographed
recorded.
There
are very few precise guidelines on how information should be recorded. It was
decided to perform a subjective audit of the notes, grading each of the four
key areas for accessibility and presence of information from A to D based upon
the Self Assessment Manual and Standards (published) by the Faculty of General
Dental Practitioners (UK), where:
A =
Clinically Excellent All
data present and easily found making clinical decisions easy
B =
Clinically Acceptable All
data present and time taken to find it doesn’t hinder clinical standards
C = Adequate (just clinically acceptable) Relevant date is found eventually
D = Clinically Unacceptable Some
data has been lost or isn’t recorded
To
make the assessment of each individual patient’s notes less subjective (and
therefore more reproducible when comparing the first audit cycle with the
second audit cycle), the exact requirements for each grade were further
defined, from A to D, for each key area. See table X
|
GRADING FOR: |
A |
B |
C |
D |
|
FP25 Chrono-logical Page Numbering and Ordering |
FP25’s
numbered and in the correct order |
FP25’s
numbered but in incorrect order |
Not every
FP25 numbered |
FP25 cards
missing or confusion over continuity of dates and treatment on them |
|
Medical History Recording |
All
information clear and last updated clearly recorded |
All
information clear but when last updated not clearly recorded |
Some
confusion over medication taken or medical condition (i.e. crossing out
present) |
Clinically
unacceptable lack of information or confusion |
|
BPE Recording |
Charted
clearly at last examination |
Charted less
than clearly at last examination |
Charted at
some point within the last 2 years |
Uncharted
within the last 2 years |
|
Radiographs |
Found easily
and correctly mounted, dated and with recording of patients name and area
radiographed |
Found easily
with only one of the above 4 criteria missing |
Not found
easily or more than one of the above 4
criteria missing |
Radiograph
written in notes as taken in the last 3 years* is missing |
* This time span was chosen because it is the
longest usual time interval between routine bitewings
being
taken – and it could be reasonably assumed that the clinician would want to
refer to these
radiographs
when the patient attended – therefore they should be present.
The
standard set for the first audit cycle was to achieve at least “clinically acceptable”
B Grades for the majority of notes and no D “clinically unacceptable”
grades.
The notes of the first 50 patients seen for a routine examination in a two-week period in December 2001 were analysed. Each of the four key areas was assessed and graded according to the above grading criteria.
The inclusion criteria were:
1. The patient had to be
dentate (so the BPE could be assessed)
2. The patient had to be an
adult (i.e. over 18)
3. A radiograph had to be written in the notes as taken in the
last three years (so accessibility of radiographic information could be
assessed). In this case the last taken
radiograph as recorded in the notes was assessed, whether it be
a PA or Bitewing. OPG’s were excluded as
they are not filed in the same way as the above and tend to be rather easy to
find!
Results for Audit Cycle 1 - Graphs
FP25s – Simple
reinforcement of the practice protocol was instigated and its importance
stressed to the whole team.
Medical History Recording To remedy the problem of recording updates to medical histories, a stamp was designed to be placed into the notes by the dental nurse at every exam. There were spaces for the date and there was enough room for changes to medical history to be recorded.
BPE Recording – to solve the main problem of BPEs not being recorded as regularly
as they should, we had a similar stamp made to the medical history stamp. The stamp includes an area for the date and
has clearly demarcated lines for filling in the BPE score for all six sextants
– this should help to reduce the few times where illegible handwriting was the
problem. The stamp is to be placed in
the notes at each examination without fail by the nurse to encourage use!
Radiographs – the solution to the problem identified with the radiographs had to
include a means for the radiographs to be stored, already mounted, in the
notes. The holder had to be capable of
clearly indicating the patient’s name, date and area radiographed, next to each
radiograph. As well the holder needed to
be larger than the envelopes we were using so they could be found more easily
within the notes and were less likely to fall out and become lost.
It was decided to try using Clear View radiograph holders which seemed
to satisfy all of the above requirements for little extra cost.
Another advantage of the Clear View holders is that they are capable of
holding a series of radiographs (i.e. bitewings taken over several years, or
endodontic procedure periapical radiographs) meaning one radiograph can easily
and quickly be compared to another.
With the improvements in place it seemed possible to raise the standard
from the first audit cycle to attaining mainly “clinically excellent” grade
A’s with no “clinically unacceptable” grade D’s.
Since obviously there would have only been improvements in the
accessibility of information from the patients’ notes since the last audit
cycle, we audited the notes of the first 50 patients seen in a two-week period
in February 2002 who had:
1. Commenced treatment
since the last audit cycle
2. Had a radiograph taken
in that time
3. Were aged over 18 and
fully dentate as before
Collated Results Graph
As can be seen from the above table of collated results the standard of
gaining a majority of Grade A’s in the four key areas was achieved. However, there were still several clinically
unacceptable grade D’s achieved with some patient notes, most notably with the
lack of recording of BPE’s at every examination.
The introduction of the BPE stamp has greatly increased the correct
recording of patient BPE’s at examinations, from 13 in audit cycle 1 to 31 in
audit cycle 2 (a 230% improvement, so it
did encourage use!), and had completely eradicated the problem of
illegibility which counted for 2 notes in the first audit cycle.
The custom stamp made for recording Medical Histories was even more
successful than the BPE stamp. In 82% of
notes the medical history was clearly recorded and the date it was updated was
clear. There were still come crossings
out which lead to 5 Grade C’s and one instance when the stamp had been used and
dated but no information recorded (grade D)!
Reinforcement of the numbering system on the FP25 cards was largely
effective although there were still occasional instances of numbering being
forgotten and cards being replaced in the wrong order. It is thought that the cards that were out of
order may have been caused in reception when patients phoned up and the
receptionist had to quickly retrieve and replace cards. We will try and remedy this by explaining the
situation to the receptionist as she was largely excluded from the
reinforcement that took place after audit cycle 1.
By far the most successful of the changes we made was the introduction
of the Clear View holders to better facilitate retrieval of radiographic
information. As we had hoped the holders
were large enough not to fall out of patient notes (no D’s were scored) and
were also much easier to find. Virtually
all radiographs were mounted correctly, only 7 B grades were scored – 3 of
these were for inadequate labelling of the radiographed area while 4 were for
the radiograph being incorrectly mounted (either upside down or back to front).
Although in this audit only my patient notes were audited, the results have been so successful that the BPE and Medical History stamps are to be introduced into the other two surgeries in the practice. The practice as a whole is also swapping over from usi