AN AUDIT OF CLINICAL RECORD KEEPING AT A TERTIARY ORAL HEALTH CENTRE IN GAUTENG.

Objectives: The aim of the audit was to appraise clinical record keeping the facilities.
Methods: A modified 9-item clinical record audit tool was developed using the HPCSA Clinical Record Keeping guidelines and the Ideal Clinic Framework from the National Department of Health. The facility’s quality compliance with clinical records was assessed.
Results: The preliminary results were that on average, the facility audited score was 61.58%.
The facility individual scores on performed were high on administrative criteria (90%); completeness of demographic data (85%) and completeness of medical complaint and medical history information (77.5%). Lower scores were recorded for information on clinical examination and treatment planning (57%). The lowest score was information related to treatment done (13.5%) and follow-up notes (17.5%).
Conclusions: Although the facility scored well on many items, overall, they were moderately compliant with the clinical record keeping guidelines and standards as outlined in the adapted provincial clinical record keeping tool.