Dental Patient Records at OAUTHC, Ile-Ife, Nigeria

OBJECTIVE: The objective of this project is to assess adequacy of patient records for use in planning, implementing, monitoring and evaluating dental care and the dental service system at Obafemi Awolowo University Ile-Ife. METHOD: The study population comprised all patients who attended the clinic from the beginning of January 1998 to December 1999. One hundred and fifty numbers were randomly selected using the EPI6 to generate the random number table. The measurement tool was a check list which encompassed 8 different sections. The checklist was composed and modified from existing dental quality assurance programmes, the validity of which had been demonstrated. RESULTS: Sex and address were only recorded in 96.6% of case notes and none contained telephone numbers. Thirty-two per cent have no records of patient’s general health at the time of presentation. Thirty –eight (25.3%) have no records of drug allergies, 68.0% no records of problems of anaesthesia, and 16.0% no history of systemic disease. There was no record at all of the existence of pacemakers or prostheses on the records. The pregnancy status was not documented in 42.6% of patients. The records indicate that 7.33% have no records of their chief complaint. CONCLUSION: The records were found to be inadequate and may not be complete reflections of the interaction between the dentists and patients.