Abstract
Background and aim: Accurate record keeping is essential in daily clinical practice. An audit of clinical records over a specific period helps practitioners to evaluate and improve their performance and deliver a better care to the patient. Recently, studies have shown that record keeping in dentistry may be inadequate. An audit of record keeping following periodontal surgical procedure/ crown lengthening surgery or for patient-reported outcomes after such procedures has yet to be published. Patient’s satisfaction survey is one of study on patient- reported outcomes, where the patient informed their satisfaction towards the treatment. This study investigated the quality of record keeping in periodontal surgery and patient satisfaction following Crown Lengthening Surgery (CLS) at the Faculty of Dentistry, University of Otago.
Method: One hundred and three clinical records from the period 2012 to 2016 were retrospectively evaluated against the developed audit criteria. Data was collected using an audit form and examined for adherence to the developed criteria. Patients’ satisfaction survey used a set of questionnaires which consisted 15 questions. Eleven questions had a 5-point Likert response format (strongly agree, agree, neutral, disagree, strongly disagree), two with numerical pain scale and two were open-ended questions.
Result: A total 103 records were audited during the five-year period of investigation. Only one record satisfied 100% of the proposed standards. The most correctly reported items were referral reason (99%), suturing material (98.1%) and post-operative instruction (92%). In contrast, the most often absent criteria in the records were post-operative medication (16%) and use of post-operative mouthwash (14%). Regarding the patient satisfaction survey, 33 patients answered the survey and able to recall the surgical experience. From that, 82% of them were satisfied with the surgery.
Conclusion: The audit found that the recordkeeping after crown lengthening procedure was inadequate and the development of a departmental guideline can improve record keeping in the future. Regarding satisfaction survey, most participants were satisfied with their crown lengthening surgery.