AN AUDIT TO IMPROVE MEDICAL HISTORY RECORDING IN GENERAL PRACTICE

Robyn Stewart - Bridgeton Health Centre

INTRODUCTION

There are a set of standards of conduct, performance and ethics that are set by the General Dental Council and govern us as dental professionals.

These are as follows;

The Standards for the dental team

1. Put patients’ interests first

2. Communicate effectively with patients

3. Obtain valid consent

4. Maintain and protect patients’ information

5. Have a clear and effective complaints procedure

6. Work with colleagues in a way that serves the interests of patients

7. Maintain, develop and work within your professional knowledge and skills

8. Raise concerns if patients are at risk

9. Make sure your personal behaviour maintains patients’ confidence in you and the dental profession

Number 4 above states to‘maintain and protect patients information ‘. The guidance says ‘you must make and keep complete and accurate patient records, including an up-to-date medical history, each time that you treat patients.’ This is the basis of this dental audit. The purpose of the audit will be to assess the accuracy and completeness of my medical histories. It is vitally important, both medico legally and for proper patient care, to ensure that medical histories are complete and up to date.

This audit will provide data demonstrating the current level of compliance with set standards. Following this, a meeting will be arranged with my dental team to discuss initial results, and change will be implemented to make any improvements required.

AIM OF AUDIT

The aim of my audit is to identify to what extent the practice maintains adequate medical histories. Its aim is to facilitate development of new practice policy which will result in improved results in the second round, and sustainable improvement for the future.

CRITERIA MEASURED

The following will be recorded:

1/ Presence of medical history

2/ Signature and date of patient

3/ Medical History updated within the last year

4/ Personal details recorded (Name, address and postcode, date of birth and contact telephone number)

5/ Recording of any medications taken

6/ Smoking history recorded

7/ Alcohol use recorded

STANDARDS USED

As mentioned in my introduction, the GDC have set standards for the dental team and these cover keeping complete and accurate patient records, including an up-to-date medical history. There are also elements of the standards identified in FGDP ‘Clinical Examination and Record-Keeping’ which provides an essential reference to the many different aspects of record-keeping and examination including recording details of medical history. There are Scottish Dental Clinical Effectiveness Programme guidelines for ‘prevention and treatment of periodontal disease’ and guidelines for ‘oral health assessment’- these also recommend that we ensure there is an up to date medical history - this will help assess risk factors for oral disease. There is also National Institute for Health and Clinical Excellence guidelines which state that the recall interval between clinical examinations is based on a patients risk for oral disease. This is based on three main areas, dental caries, periodontal disease, oral cancer - some risk factors can be based upon findings recorded in a medical history such as smoking and alcohol consumption. This also highlights the importance of recording an up to date medical history.

The obvious target should be 100% compliance, for all criteria measured. For the purpose of this audit project, at the end of round 2 a minimum compliance level of 90% for each criterion measured will be expected, with the exception of criterion 1 (presence of medical history). For criterion 1, at the end of round 2 a compliance level of 100% will be expected.

METHOD

I retrospectively reviewed the clinical notes of seventy five randomly selected patients that have attended the practice over 3 months prior to the audit start date. From the notes I recorded if the above criteria had been documented. I recorded this in an excel document as seen below.

I collected the data and analysed it. I then met with all practice staff and I presented my findings to them, along with my proposals for change.

It was evident that patients were only filling out parts of the medical history forms. With the business of a working day, there were times when I didn’t question the patients about the parts they had not filled in. After this discovery I made changes to my practice and devised a new protocol. When a patient checks in for an examination/toothache or recall appointment, the receptionist will give them a medical form and explain what they need to fill out. They then hand in the form to the receptionist when they are finished and she checks if any parts are missing. This is so that when I call the patient in, I can ask them about the missing sections on the form. For any patients that struggle with the form - I ask the questions and fill the form in for them and get them to sign it at the end.

After this change I reviewed the notes of seventy five randomly selectedpatients that had attended in the 2 months after the change.

RESULTS

Medical History Recording - Data Collection Round 1

Record No / Medical History Available / Signed by Patient / Updated within last 12 months / Personal
details recorded / Medications recorded / Smoking History recorded / Alcohol Use recorded
1 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
2 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
3 / Yes / Yes / Yes / Yes / No / Yes / No
4 / Yes / Yes / Yes / Yes / Yes / Yes / No
5 / Yes / Yes / Yes / Yes / Yes / Yes / No
6 / Yes / Yes / Yes / Yes / Yes / Yes / No
7 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
8 / Yes / Yes / Yes / Yes / Yes / Yes / No
9 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
10 / Yes / Yes / Yes / Yes / Yes / Yes / No
11 / Yes / Yes / Yes / Yes / Yes / No / Yes
12 / Yes / Yes / No / Yes / No / Yes / No
13 / Yes / Yes / Yes / Yes / Yes / Yes / No
14 / Yes / No / Yes / Yes / Yes / Yes / Yes
15 / Yes / No / Yes / Yes / Yes / Yes / Yes
16 / Yes / Yes / Yes / Yes / Yes / Yes / No
17 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
18 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
19 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
20 / Yes / Yes / Yes / No / Yes / Yes / Yes
21 / Yes / No / Yes / Yes / Yes / Yes / Yes
22 / Yes / Yes / Yes / Yes / No / Yes / Yes
23 / Yes / No / Yes / Yes / Yes / Yes / Yes
24 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
25 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
26 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
27 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
28 / Yes / Yes / Yes / Yes / No / Yes / Yes
29 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
30 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
31 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
32 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
33 / Yes / Yes / Yes / No / No / Yes / No
34 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
35 / Yes / Yes / Yes / Yes / Yes / Yes / No
36 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
37 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
38 / Yes / Yes / Yes / Yes / No / Yes / Yes
39 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
40 / Yes / Yes / Yes / Yes / No / Yes / Yes
41 / Yes / Yes / Yes / Yes / Yes / No / No
42 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
43 / Yes / No / Yes / Yes / No / Yes / Yes
44 / Yes / Yes / Yes / Yes / Yes / No / No
45 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
46 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
47 / Yes / Yes / Yes / Yes / Yes / Yes / No
48 / Yes / Yes / Yes / No / No / Yes / Yes
49 / Yes / Yes / Yes / Yes / No / No / No
50 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
51 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
52 / Yes / Yes / No / Yes / No / No / No
53 / Yes / Yes / Yes / Yes / Yes / Yes / No
54 / Yes / Yes / Yes / Yes / Yes / Yes / No
55 / Yes / Yes / Yes / Yes / Yes / Yes / No
56 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
57 / Yes / Yes / Yes / Yes / Yes / Yes / No
58 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
59 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
60 / Yes / Yes / Yes / Yes / Yes / No / No
61 / Yes / Yes / Yes / Yes / Yes / Yes / No
62 / Yes / Yes / Yes / Yes / Yes / No / No
63 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
64 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
65 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
66 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
67 / Yes / No / No / No / Yes / No / No
68 / Yes / Yes / Yes / Yes / Yes / No / No
69 / Yes / No / Yes / Yes / Yes / Yes / No
70 / Yes / Yes / No / Yes / Yes / Yes / Yes
71 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
72 / Yes / Yes / Yes / Yes / Yes / Yes / No
73 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
74 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
75 / Yes / Yes / Yes / Yes / Yes / Yes / Yes

Medical History Recording - Data Collection Round 2

Record No / Medical History Available / Signed by Patient / Updated within last 12 months / Personal
details recorded / Medications recorded / Smoking History recorded / Alcohol Use recorded
1 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
2 / Yes / Yes / Yes / Yes / Yes / Yes / No
3 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
4 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
5 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
6 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
7 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
8 / Yes / No / Yes / Yes / Yes / Yes / Yes
9 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
10 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
11 / Yes / Yes / Yes / Yes / Yes / Yes / No
12 / Yes / yes / Yes / Yes / Yes / Yes / No
13 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
14 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
15 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
16 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
17 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
18 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
19 / Yes / No / Yes / Yes / Yes / Yes / No
20 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
21 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
22 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
23 / Yes / No / Yes / No / Yes / Yes / Yes
24 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
25 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
26 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
27 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
28 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
29 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
30 / Yes / No / Yes / Yes / Yes / Yes / No
31 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
32 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
33 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
34 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
35 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
36 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
37 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
38 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
39 / Yes / No / Yes / No / Yes / Yes / Yes
40 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
41 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
42 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
43 / Yes / No / Yes / Yes / Yes / Yes / Yes
44 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
45 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
46 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
47 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
48 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
49 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
50 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
51 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
52 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
53 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
54 / Yes / Yes / Yes / Yes / Yes / No / No
55 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
56 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
57 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
58 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
59 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
60 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
61 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
62 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
63 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
64 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
65 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
66 / Yes / No / Yes / Yes / Yes / Yes / Yes
67 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
68 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
69 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
70 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
71 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
72 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
73 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
74 / Yes / Yes / Yes / Yes / Yes / Yes / Yes
75 / Yes / Yes / Yes / Yes / Yes / Yes / Yes

Results total

Result round / Medical History Available / Signed by Patient / Updated within last 12 months / Personal
details recorded / Medications recorded / Smoking History recorded / Alcohol Use recorded
1 / 100% / 91% / 95% / 95% / 85% / 88% / 52%
2 / 100% / 91% / 100% / 97% / 100% / 99% / 92%

DISCUSSION

On examination of my audit results it is clear that my practice has improved and that my standard has been achieved as there has been a clear increase in recording of medical history detail. I achieved a level of 90% or above for each criterion measured in the second round, with the exception of criterion 1 (presence of medical history)which I had a 100% compliance in both rounds.

The 3 results which stood out the most were the recording of medication which increased from 85% to 100%, smoking history from 88% to 99% and the biggest increase was in recording of alcohol use. This increased from 52% to 92%.