Improving the Quality of Oral and Maxillofacial Surgical Notes in an Indian Public Sector Hospital in Accordance with the Royal College of Surgeons Guidelines: A Completed Audit Loop Study

Aim

Proper and adequate documentation in operation notes is a basic tool of clinical practice with medical and legal implications. An audit was done to ascertain if oral and maxillofacial surgery operative notes in an Indian public sector hospital adhered to the guidelines published by the Royal College of Surgeons England.

Methods

Fifty randomly selected operative notes were evaluated against the guidelines by RCS England with regards to the essential generic components of an operation note. Additional criteria relevant to oral and Maxillofacial Surgery were also evaluated. Changes were introduced in the form of Oral and Maxillofacial Surgery specific consent forms, diagram sheets and a computerized operation note proforma containing all essential and additional criteria along with prefilled template of operative findings. Re-audit of 50 randomly selected operation notes was performed after a 6 month period.

Results

In the 1st audit cycle, excellent documentation ranging from 94 to 100 % was seen in 9 essential criteria. Unsatisfactory documentation was observed in criteria like assistant name, date of surgery. Most consent forms contained abbreviations and some did not provide all details. Additional criteria specific to Oral and Maxillofacial Surgery scored poorly. In the 2nd Audit for loop completion, excellent documentation was seen in almost all essential and additional criteria. Mean percentage of data point inclusion improved from 84.6 to 98.4 % (0.001< P value <0.005). The use of abbreviations was seen in only 6 notes.

Conclusion

Regular audits are now considered a mandatory quality improvement process that seeks to improve patient care and outcomes. To the best of our knowledge, this is the first completed audit on operation notes documentation in Oral and Maxillofacial Surgery from India. The introduction of a computerized operation note proforma showed excellent improvement in operation note documentation. Surgeons can follow the RCS guidelines to ensure standardization of operation notes.

     

A comparison of computer‐ and hand‐generated clinical dental notes with statutory regulations in record keeping

Introduction: Dental patient records should be of high quality, contain information to allow for good continuity of care and clinical defence (should the need ever arise) and, ideally, facilitate clinical audit. Handwritten dental records have been assessed for their compliance to statutory regulations, but the same cannot be levelled at computer‐generated notes. This study aimed to compare and analyse the compliance of both methods of data recording with statutory regulations. Method: Fifty consecutive sets of handwritten notes and 50 sets of computer‐generated notes were audited for compliance with a number of legal requirements and desirable characteristics for dental records and the results compared. The standard set for compliance with all characteristics was 100%. Results: The computer‐generated notes satisfied the set standard for 8 of the 11 legal requirements and three of six desirable characteristics. The handwritten notes satisfied the set standard for 1 of 11 legal requirements and none of the desirable characteristics. A statistical difference (using a 95% confidence interval) between the two methods was observed in 5 of 11 legal characteristics and three of six desirable characteristics, all of which were in favour of computer‐generated notes. Conclusions: Within the limitations of this study, computer‐generated notes achieved a much higher compliance rate with the set parameters, making defence in cases of litigation, continuity of care and clinical audit easier and more efficient.     

A review of technical notes published in BJOMS: a comparison 10 years on

Technical notes are known to be a popular method of publishing novel surgical techniques, up-to-date technological advances, and tricks of the trade in oral and maxillofacial surgery (OMFS). The British Journal of Oral and Maxillofacial Surgery (BJOMS) has a dedicated section for such papers, and this article explores the publication of technical notes over the last two years. In addition, comparison is made with previous reviews of technical notes in this journal a decade ago, to explore the progression of diversity and evolving topics of interest to the oral and maxillofacial surgery community.     

A survey of the first 6 years of experience with cone beam CT scanning in a teaching hospital orthodontic department

Abstract

Objective: Cone beam computed tomography (CBCT) is a specialized form of radiography and has been used in the Glasgow Dental Hospital since 2006. The clinical notes of all patients referred for CBCT from the orthodontic department between 2006 and 2011 were evaluated to determine the reasons for referral, scan parameters and clinical findings.

Design: Retrospective observational study.

Materials and methods: From a general database, the notes of patients from the Orthodontic Department of Glasgow Dental Hospital & School referred for CBCT imaging, since the inception of the service (2006 through to 2011) were examined. Information was obtained from CBCT request forms, case notes and radiology reports.

Results: During the chosen time period, 290 patients were referred for CBCT. Of these, 280 had clinical records that were available for investigation. Analysis showed approximately a third of scans were carried out within 4 weeks of referral. The smallest height of 4 cm was used for over a third of the scans investigated. Sixty-two per cent of the scans examined the maxilla only, 32% both jaws and 6% the mandible only. The two most common reasons for referral were to accurately determine the position of impacted teeth and to identify the presence of root resorption in relation to impacted teeth. In this cohort, 39% of teeth adjacent to an impacted tooth were found to have some root resorption, which closely supports the current literature.

Conclusions: This study provides a general overview of CBCT used by an orthodontic department in a teaching hospital environment.     

The CRABEL score--setting standards in maxillofacial medical note-keeping

The CRABEL score (developed by Crawford, Beresford and Lafferty) was introduced for auditing medical note-keeping at Morriston Hospital in June 2001. Guidelines detailing the scoring system were issued to all clinicians in the maxillofacial unit. An auditor selected two sets of medical notes from each consultant's firm, giving an initial allocation of 100points/firm (50 points for each set of notes). The notes of the most recent in-patient admission were analysed using the CRABEL marking sheet to give a score out of 100 for each firm. The audit was repeated at 3-month-intervals. CRABEL scores within the maxillofacial unit improved from 70 to 97. The CRABEL score is simple, reliable and repeatable. It is a successful and objective measure for audit and for improvement in the quality of note-keeping. We propose that it be adopted in maxillofacial units throughout the United Kingdom.     

Revisiting comfort: strategies observed in the direct observation study

The Surgeon General's 2000 report on oral health found that one-third of adults in the U.S. had not visited a dentist in the previous year. Fear of treatments received during a dental encounter can create a barrier to patients receiving care. Most studies of dental anxiety have focused on phobic patients; relatively few studies have explored attempts to provide comfort and alleviate anxiety among everyday patients. This study describes comforting strategies that were performed by dentists, dental assistants, and hygienists for their patient population as a whole. As part of the Direct Observation Study, 120 dental practices in Ohio were observed over a four-day period by trained research hygienists. Researchers observed and recorded 3,800 patient interactions with dentists and hygienists at 30-second intervals using 24 behavior-specific codes. In addition, observers composed qualitative notes detailing the patient visits and recorded in their notes specific comforting techniques performed by dentists, hygienists, and dental assistants.     

Technical notes published in BJOMS over a 2-year period—Should we be doing it differently?

Between January 2007 and December 2008, 44 technical notes or related publications (such as letters) were published in the British Journal of Oral and Maxillofacial Surgery (BJOMS). These covered most of the remit of the specialty and ranged from operative surgical techniques to the use of digital photographs to orientate surgical specimens. However, there would seem to be very little feedback on the value of these articles in everyday practice.     

Improving the Standard of Operative Notes within an Oral and Maxillofacial Surgery Department,using an Operative Note Proforma

Aim  

The operative note needs to be an accurate and legible account of events occurring in the surgeon’s theatre. We set out to discover if operative notes within a British District General Oral and Maxillofacial Surgery department adhered to Royal College of Surgeons (England) guidelines.     

The school dental therapist of South Australia

The writer of this paper, without notes as a guide, presented a remarkable discussion, during the annual luncheon, on the School Dental Therapist's activity in the School Dental Service of South Australia. Public Health dentists in the United States now have an opportunity to read the formal report.     

The role for 'reminders' in dental traumatology: 2. The effectiveness of a reminder stamp compared with the current clinical practice for documenting the diagnostic working length

Abstract –  The aim of this study was to establish if a predesigned prompt in the form of a reminder stamp placed in a patient's dental records is more effective for recording the essential details of a diagnostic working length compared to the current practice without any specific prompts. Following a pilot study of current practice, a stamp was introduced. Twelve months following the introduction of the stamp, 198 patient records were examined, where endodontic treatment had been carried out mainly for traumatic injuries. The following parameters were specifically investigated whether a radiograph had been taken to establish working length and was it available for examination, whether the working length was recorded in the notes and whether a reference point for the measurements was given. The working length was conventionally recorded by 127 notes, whereas 71 used the stamp. A working length radiograph was taken and a working length recorded for 95% of the cases where no stamp had been used, compared to 100% of the stamp group. Where no stamp had been used only 83% of working length radiographs were available compared to 100% of the stamp group. Interestingly, a reference point from where the working length had been measured was only recorded in 5% of the cases where the stamp had not been used compared to 94% using the predesigned stamp. This result was statistically significant using a chi-squared test ( P  < 0.001). The stamp was generally more effective than the conventional method of recording the working length for endodontics.     

Sarcomas of the oral and maxillofacial region: a review of 88 cases in Zimbabwe

We reviewed the case notes of 88 patients who were treated for sarcomas of the oral and maxillofacial region over a period of 24 years. There were 51 men (mean age 23 years) and 37 women (mean age 29). Forty-six tumours were in the mandible. Osteosarcoma accounted for 31 cases, and rhabdomyosarcoma 21 (usually under the age of 10 years).     

A synopsis of oncology and oncology-related papers published in the British Journal of Oral and Maxillofacial Surgery 2007–2008

This paper provides a summary of the 95 papers related to oncology that were published in the British Journal of Oral and Maxillofacial Surgery (BJOMS) during 2007–2008. They include full length articles on clinical studies, radiology, basic science, and reconstruction in oral, and head and neck cancer. The journal also publishes technical notes and short communications. It encompasses the whole remit of the specialty and it is encouraging that authors choose to submit their work to BJOMS, but to improve the quality and status of the journal, we need to increase the ratio of full length articles to other submissions.Reviews of other subspecialties will be published in due course.     

Management of Medical Records: Facts and Figures for Surgeons

Medical records are the document that explains all detail about the patient’s history, clinical findings, diagnostic test results, pre and postoperative care, patient’s progress and medication. If written correctly, notes will support the doctor about the correctness of treatment. Inspite of knowing the importance of proper record keeping in India, it is still in the initial stages. Medical records are the one of the most important aspect on which practically almost every medico-legal battle is won or lost. This article discusses the various aspect of record maintenance.     

A standardised preprinted template for recording of maxillofacial oncological operations

Completion of accurate and legible operating notes are the clinician's responsibility. They require time, precision, concentration and legibility. A preprinted template helps meet these needs and complies with the guidelines of the Royal College of Surgeons.     

No man's craniosynostosis: the arcana of sutural knowledge

No man's craniosynostosis is discussed under the following headings: historical notes, sutural development, suture closure, craniosynostotic patterns, anatomic and genetic perspectives, types of craniosynostosis, and 2 unusual types of craniosynostosis with large head circumferences.     

Comparison of treatment result and compliance between private practice Medicaid and non-Medicaid orthodontic patients--a brief communication

Treatment result and compliance for orthodontic Medicaid patients were assessed and compared to non-Medicaid patients of similar initial severity. All 55 North Carolina practices providing orthodontic treatment covered by Medicaid were asked to submit their last five Medicaid cases and five non-Medicaid cases of similar initial treatment complexity Nine practices agreed to participate. Initial models, final models, and progress notes were obtained for all subjects. Casts were scored using the Peer Assessment Rating (PAR) Index to assess initial and posttreatment orthodontic status, and progress notes were reviewed for compliance data. No clinically important differences were seen between the Medicaid and non-Medicaid groups with respect to initial PAR, final PAR, percent PAR reduction, broken appointments, broken appliances, or poor oral hygiene. In this study, Medicaid and non-Medicaid patients did not differ substantially with respect to effectiveness of treatment received or their compliance with treatment.     

Technical quality of root canal fillings done in a Nigerian general dental clinic

Background

Previous reports indicate that worldwide, the technical quality of root canal fillings is poor. There are few reports from sub-Saharan Africa and none yet from Nigeria where most patients access treatment from non-specialists especially at general dental clinics. The aim of this study was to evaluate the technical quality of root canal fillings done in a general dental clinic with emphasis on the effects of professional experience of the operator, whether tooth was anterior or posterior and whether it was a maxillary or mandibular tooth.

Methods

Retrospective study of case notes and periapical radiographs of patients with completed root canal fillings seen between 2008 and 2011. Inclusion criteria included cases of primary treatment with available case notes, good quality pre-operative and post-operative periapical radiographs. Technical quality that was assessed was root canal length and homogeneity. Root canal fillings were classified either as Good Quality Endodontic Work (GQEW) or Non- Good Quality Endodontic Work (NGQEW).

Results

Fifty-one patients aged between 8 and 54?years (mean 28) fulfilled the inclusion criteria for this study. From these, there were 62 root filled teeth giving a ratio of 1.2 root canal filled teeth per person. There were acceptable length of root canal fillings in 71% of teeth, 58.1% were homogeneous while 53.2% were GQEW. There was no statistically significant difference in whether tooth was root filled by junior or senior dentist (p?=?0.43), anterior or posterior (p?=?0.11). There was significant association between GQEW and maxillary teeth (p?=?0.03).

Conclusion

This study showed that the overall technical quality of root canal fillings done by non-specialists was better than earlier reports but lower than that done by endodontists. Since many patients receive treatment from non-specialists in developing countries, it is necessary to improve technical quality of root canal fillings done in general dental clinics. These could be through improvement in the quality of undergraduate training and more post graduate continuing education courses for skills update.     

Identification concept and the use of probabilities in forensic odontology--an approach by philosophical discussion

This paper questions the practitioners' deterministic approach(es) in forensic identification and notes the limits of their conclusions in order to encourage a discussion to question current practices. With this end in view, a hypothetical discussion between an expert in dentistry and an enthusiastic member of a jury, eager to understand the scientific principles of evidence interpretation, is presented. This discussion will lead us to regard any argument aiming at identification as probabilistic.     

Data-driven method to enhance craniofacial and oral phenotype vocabularies

BackgroundA significant amount of clinical information captured as free-text narratives could be better used for several applications, such as clinical decision support, ontology development, evidence-based practice, and research. The Human Phenotype Ontology (HPO) is specifically used for semantic comparisons for diagnostic purposes. All these functions require quality coverage of the domain of interest. The authors used natural language processing to capture craniofacial and oral phenotype signatures from electronic health records and then used these signatures for evaluation of existing oral phenotype ontology coverage.MethodsThe authors applied a text-processing pipeline based on the clinical Text Analysis and Knowledge Extraction System to annotate the clinical notes with Unified Medical Language System codes. The authors extracted the disease or disorder phenotype terms, which were then compared with HPO terms and their synonyms.ResultsThe authors retrieved 2,153 deidentified clinical notes from 558 patients. Finally, 2,416 unique diseases or disorders phenotype terms were extracted, which included 210 craniofacial or oral phenotype terms. Twenty-six of these phenotypes were not found in the HPO.ConclusionsThe authors demonstrated that natural language processing tools could extract relevant phenotype terms from clinical narratives, which could help identify gaps in existing ontologies and enhance craniofacial and dental phenotyping vocabularies.Practical ImplicationsThe expansion of terms in the dental, oral, and craniofacial domains in the HPO is particularly important as the dental community moves toward electronic health records.     

Endodontics of the 19th century

The first steps of Endodontics, and specially those of the 19th century, are hardly known with unpublished and profitable to technical efforts for present specialty. We begin here a series of historic notes about the subject, hoping to know some further information to be provided by other colleagues verses in this matter.