Resumen de Dental audit (I): exact criteria of dental records; Results of a Phase-III study

María del pilar Martín García, José Vicente Ríos Santos, Juan J. Segura Egea, Ana Fernández-Palacín, Pedro Bullón

• Objective: Evaluating the quality of dental records in the Faculty of Dentistry of the University of Seville (Spain).

  We attempted to collect and/or develop identifiable elements of dental care used to evaluate its appropriateness, as well as to measure its level of filling-in between 1999 and 2004 (Phase III of the record audit).

  Method: The 46 criteria used to evaluate dental care are shown, measuring —in 50 dental records randomly chosen within a 5-year-time period— their level of filling-in (Phase III of a health audit).

  Results: A low level of filling-in was observed in all quality criteria defined. No record was found to be free from errors. A maximum of 36 criteria out of 46 was fulfilled (mean of 20.8).

  Conclusions: The standard of appropriate filling-in was only met in 12 criteria (75 %), the results being poor, due to the importance which clearly deficient aspects related to diagnosis and treatment plan have in the process of patient care. For such reason, we suggest a remedial action (Phase IV) developing a new model of dental record and its subsequent re-evaluation (Phase V), which will be subject to analysis in the second part of this paper.