Dental Patient Records in a Nigerian Tertiary Health Care Institution

OBJECTIVES: The aim of this project is to provide information about the adequacy of patient records for use in planning, implementing, monitoring and evaluating dental care and the dental service system at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. METHODS: One hundred and fifty records were randomly selected from the list of all patients who attended the dental clinic from the beginning of January 1998 to the end of December 1999. These were evaluated using a checklist which encompassed 8 different sections. Each of the sections included variables which were scored in four categories; Present, Absent, Not Available or Not Applicable. The checklist was composed and modified from existing dental quality assurance programmes, the validity of which had been demonstrated (Demby, Rosenthral and Angello, 1990). The contents of the patients' records were compared to recommended guidelines. RESULTS: Neither sex nor address was recorded in 3.4% of the records. None contained telephone numbers of the patient. Also, the following important parameters were not indicated in the percentages specified: patient's general health, 32.0%; history of drug allergies, 25.3%; problems with anaesthesia, 68%; history of systemic diseases, 16.0%; pregnancy status, 42.6%; chief complaint, 7.3%; complications with past dental treatment, 16.6%; oral hygiene practices, 29.3%; and oral habits, 29.3%. There was no record of tooth charting in 10.0%. CONCLUSIONS: The records were found to be inadequate and may not be complete reflections of interactions between patients and dentists. In most cases, litigation and risk management requirements were not met.