Soft Tissue Audit.
Final report.
An audit was conducted to assess the level of recorded soft tissue examinations in a random sample of 50 adult patients over the previous 2 years since the start of the audit in 2015 and did they meet with the criteria set by SIGN guidelines. Subjectively it was felt that soft tissue examinations were being done at patients’ routine recall examinations but not being recorded fully in the clinical notes.
It was difficult to assess clinical records prior to 2013 as a new clinical management computer system was installed and there was a major problem with the transfer of clinical notes to the new system from the old. The old system could be accessed but only with some difficulty. It was not directly compatible and the records were held in another older computer. It was felt that there was enough meaningful date from 2013 to render the audit of use, as examination protocols had not changed, so records prior to 2013 were not included.
As said before, from 2013, 50 adult records were reviewed.
All had CPITN and periodontal status recorded. Also recorded were smoking status, presenting complaint, and soft tissue health. The patients all had soft tissue examinations recorded as having been done but no specific sites recorded. Where no lesions were detected, the record was shown to record “soft tissues normal”.
Within this cohort no abnormal soft tissue lesions were recorded.
Reviewing the results and comparing the with SIGN guidelines our recording notes were deficient.
Action.
Discussion took place as to how we could improve our examination protocols.
The computer software was rewritten to include a full soft tissue examination.
This was able to be done in house as the software (SOE) already had exam protocols included and could be accessed from drop down menus. The exam progam now includes check boxes to prompt examination of the recommended soft tissue areas at each examination. Should an area not be checked as normal, a note is made in the clinical record and the area shown in a graphic representation of the oral cavity within the clinical progam. This part allows for a differential provisional diagnosis to be entered. If this area of the clinical notes has an entry, it is flagged in the patient notes.
Outcome.
Since instigating the changes above, a further examination of 50 patient records who had examinations carried out, revealed a 100% compliance with soft tissue recording. No patients seen had soft tissue lesions.
Discussion.
Initially I felt that I recorded soft tissue health routinely and satisfactorily. Since 1980, when I went into general dental practice, I have seen 6 patients with oral/ perioral cancer. Four were intra oral squamous cell carcinoma, one was malignant intraoral melanoma and the last one was basal cell carcinoma extra orally. Cancer of the mouth fortunately, is not common. I see numerous people who smoke and this is recorded. This would appear to be related to the socio economic group where the practice is based and serves. Tobacco use counselling is offered but more than often declined.
In view of the burgeoning possibility of litigation, record keeping is becoming of more importance. There have been several cases, recently, of GDC investigations of records where the GDC felt the records were inadequate. Many of these cases were dismissed with “no case to answer”. This would have been somewhat distressful for the clinician involved and expensive for the profession as a whole.
Guidelines an record keeping are to be recommended.
Conclusions.
The Audit was of value in that it indicated areas for improvement as regards soft tissue examination. New protocols have been placed.