Clinical audit is defined as a quality improvement

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1 Clinical Audit Teaching in Record-Keeping for Dental Undergraduates at International Medical University, Kuala Lumpur, Malaysia Jun A. Chong; Jamie K.Y. Chew; Sneha Ravindranath, M.D.S.; Allan Pau, Ph.D. Abstract: This study investigated the impact of clinical audit training on record-keeping behavior of dental students and students perceptions of the clinical audit training. The training was delivered to Year 4 and Year 5 undergraduates at the School of Dentistry, International Medical University, Kuala Lumpur, Malaysia. It included a practical audit exercise on patient records. The results were presented by the undergraduates, and guidelines were framed from the recommendations proposed. Following this, an audit of Year 4 and Year 5 students patient records before and after the audit training was carried out. A total of 100 records were audited against a predetermined set of criteria by two examiners. An survey of the students was also conducted to explore their views of the audit training. Results showed statistically significant improvements in record-keeping following audit training. Responses to the survey were analyzed qualitatively. Respondents reported that the audit training helped them to identify deficiencies in their record-keeping practice, increased their knowledge in record-keeping, and improved their recordkeeping skills. Improvements in clinical audit teaching were also proposed. Jun Ai Chong and Jamie Kwai Yee Chew are dental undergraduates, School of Dentistry, International Medical University, Kuala Lumpur, Malaysia; Dr. Ravindranath is Senior Lecturer in Orthodontics, School of Dentistry, International Medical University, Kuala Lumpur, Malaysia; and Dr. Pau is Professor in Dental Public Health, School of Dentistry, International Medical University, Kuala Lumpur, Malaysia. Direct correspondence and requests for reprints to Dr. Allan Pau, School of Dentistry, International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, Kuala Lumpur, Malaysia; phone; allan_pau@imu.edu.my. Keywords: clinical education, clinic management, patient records, clinical audit, record-keeping, dental education, Malaysia Submitted for publication 1/15/13; accepted 4/29/13 Clinical audit is defined as a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. 1 It is often considered as part of continuing professional development and in some contexts is a mandatory requirement for specialist training and registration. 2 During the audit process, deficiencies in current practice against set standards are highlighted, and improvements are implemented for better service delivery and outcomes. 3 Recognition of error is critical if quality in care is to be addressed. 4 The use of clinical audit in dental practice has been widely documented To prepare the dental graduate for audit in independent clinical practice, the Association for Dental Education in Europe (ADEE) has recommended that, on graduation, a dentist must be competent at audit and clinical governance. 12 Increasingly, training in clinical audit as part of undergraduate dental education has also been reported In embracing the ethos of clinical audit in improving the quality of care, the School of Dentistry at the International Medical University (IMU), Kuala Lumpur, Malaysia, introduced clinical audit training as part of the undergraduate curriculum. Clinical record-keeping was chosen as the subject for audit since it has been the subject of audit in a number of research reports. 7,14,16,17 Clinical record-keeping is described as a continuous detailed documentation of a patient s health condition that is essential for delivery of competent care. 18,19 It ensures appropriate continuity of care, especially when the patient is seen by more than one care provider. The oral health of a patient is also monitored through continuous assessment of care given. Additionally, good recordkeeping is essential because clinical records are important legal documents that provide information to the dentist, patient, and any authorized third party in line with the recognition that good records facilitate good defense, poor records a poor defense, and no records no defense. 19 The aim of this article is to describe the implementation of clinical audit training in the dental undergraduate curriculum at IMU, investigate its impact on record-keeping behavior, and explore students perceptions of the audit training. 206 Journal of Dental Education Volume 78, Number 2

2 Methods At the time of delivering the audit training, patient records at the Oral Health Centre at IMU were stored electronically in a practice management software system (OpenDent) and a student assessment portal. The medical history, dental history, and extraoral findings were stored in the student assessment portal, while the remaining information was stored in the OpenDent. This inconsistency in record-keeping was identified as a risk for quality patient care. To address this issue, training in recordkeeping audit was delivered separately to Year 4 and Year 5 undergraduates. There were sixteen students in Year 4 and nine in Year 5. The training included the following. First was a plenary on the principles and methodologies of clinical audit (ten minutes). It was presented by a student. Second was a seminar on record-keeping in which students researched record-keeping criteria and standards and developed a protocol for auditing patient records (one hour). The whole process was student-driven in which the students decided on the criteria after discussion with the tutor. The Year 4 students worked in two groups and Year 5 students in one group. Third, in the clinical audit exercise, two patient records from each student were audited by two of their peers (thirty minutes). Each record was scored on whether a set of criteria were met, not met, or not sure. The scores for each record on each criterion were averaged. Finally, the students presented the results of their audit to their peers and proposed recommendations for improving record-keeping (thirty minutes). The recommendations made by the students were framed into guidelines. These were disseminated to both staff and students through staff and class meetings. The guidelines were also posted onto the desktop of individual computers at patient treatment cubicles. The guidelines consisted of ten domains, each with a number of criteria that were agreed to be essential for good record-keeping. For example, in the Medical History domain, there were three criteria: records of known allergies and drug sensitivities, current medication, and medical conditions. Three months after the audit training, an audit of patient records kept by the students before and after the audit training was carried out. Records of two patients treated by students before the audit training and two who commenced treatment after the training were selected for audit. A total of 100 records were selected on the basis of four records per student. Records of patients with two providers (or treated by two clinicians) were excluded. Each record was audited against the set of criteria that had been previously developed. A data collection form was constructed and used to extract the data. Two of the authors (JAC and JKYC) audited the patient records independently. The presence or absence of recording of each criterion was noted. Where the examiners disagreed, the record was reviewed and a consensus was reached. Data were entered into SPSS 18.0 (SPSS, Inc., Chicago, IL, USA) for analysis. The number and percentage of records that met each criterion were calculated. A chi-square test for association was carried out to test for statistically significant differences in the recording of the record-keeping criteria pre- and post-audit training. The mean number of criteria recorded in each domain was calculated, and statistically significant differences were compared between pre- and post-audit training. Finally, comparison of means for each domain was carried out after controlling for year of study. Statistical significance was set at p<0.05. An survey was also conducted to explore the views of the students on audit and recordkeeping. The following four questions were asked to solicit qualitative responses: 1) Did you find the clinical audit training that you had in the previous semester useful? If yes, what were the benefits that you gained from it? If no, what were the reasons? 2) How has the clinical audit exercise impacted on your record-keeping? 3) What were the shortcomings of the clinical audit training, and how do you think we can improve it for the next clinical audit training session? 4) What more would you like to learn from clinical audit training? The students were assured that the responses they volunteered would be treated confidentially. Data analysis was carried out using the Framework methodology, which involves systematically sifting, indexing, and charting the data collected according to key issues and themes. This clinical audit was approved by the School Management Committee. Results Quantitative Analysis In total, fifty pre-training and forty-eight posttraining records were identified because two students had completed only one course of treatment each for their patients. The number and percentage of records February 2014 Journal of Dental Education 207

3 Statistically significant improvements were observed for the medical history, dental history, and extraoral examination domains. Dental charting was present in all records, but not soft tissue or periodontal charting. Although there was a statistically significant improvement in recording of soft tissue observathat met each criterion pre- and post-training are shown in Table 1. Under personal details, registration number, name, gender, and date of birth were completely recorded. There were variations for the remaining criteria, but differences in pre- and posttraining records were not statistically significant. Table 1. Number and percentage of records fulfilling the audit criteria pre- and post-training Pre-Training Post-Training Criteria n (%) n (%) p-value 1. Personal Details Registration number 50 (100%) 48 (100%) Name 50 (100%) 48 (100%) Gender 50 (100%) 48 (100%) Date of birth 50 (100%) 48 (100%) Address 46 (92.0%) 41 (85.4%) Contact number 50 (100%) 46 (95.8%) Primary provider 50 (100%) 48 (100%) Emergency contact name 45 (90.0%) 45 (93.8%) Emergency contact number 45 (90.0%) 43 (89.6%) 2. Medical History Known allergies and drug sensitivities 6 (12.0%) 37 (77.1%) Medical condition 8 (16.0%) 37 (77.1%) Current medication 6 (12.0%) 36 (75.0%) Dental History Chief complaint 23 (46.0%) 42 (87.5%) History of complaint 14 (28.0%) 40 (83.3%) Previous dental experience 2 (4.0%) 32 (66.7%) Oral hygiene practices 1 (2.0%) 30 (62.5%) Extraoral Examination Facial symmetry 0 26 (54.2%) TMJ 1 (2.0%) 34 (70.8%) Lymph nodes 0 32 (66.7%) Lips 0 27 (56.3%) Smile analysis 0 24 (50.0%) Intraoral Examination Soft tissues 2 (4.0%) 9 (18.8%) Dental charting 50 (100%) 48 (100%) Periodontal charting 10 (20.0%) 17 (35.4%) Investigations Investigations 8 (16.0%) 20 (41.7%) Diagnosis Diagnosis 19 (38.0%) 39 (81.3%) Treatment Plan List of treatment plan 39 (78.0%) 45 (93.8%) Name of supervisor approved for treatment plan 0 1 (2.1%) Date of treatment plan 50 (100%) 48 (100%) 9. Procedures Detailed procedure descriptions 31 (62.0%) 37 (77.1%) Date of procedures done 50 (100%) 48 (100%) 10. Updated Records Updated records 46 (92.0%) 45 (93.8%) Journal of Dental Education Volume 78, Number 2

4 tions post-training, the proportion of records with this recording was low (18.8 percent). Statistically significant improvements were also observed in recording of investigations carried out (inclusive of interpretations of results), diagnosis made, and treatment planned. The mean numbers of criteria met within each domain pre- and post-training are shown in Table 2. There was statistically significant improvement in the number of criteria recorded post-training in seven of the ten domains. Overall, twenty-four criteria were recorded post-training compared to sixteen pre-training (p=0.001). The results of comparing the mean number of criteria met pre- and post-training for Year 4 and 5 students are shown in Table 3. Year 4 students showed more improvement than Year 5 students. Overall, Year 4 students recorded twentyfive criteria post-training compared to sixteen pretraining, whereas Year 5 students recorded twentythree post-training compared to sixteen pre-training. Qualitative Analysis Of the twenty-five students surveyed by , eighteen responded with qualitative feedback. Responses were categorized into four main themes: knowledge, attitude, and behavior around audit and record-keeping and views of the audit training. There were no differences in views between genders. Most students reported that the training in clinical audit showed them the shortcomings of their record-keeping and highlighted the need for improvement. For example, a female Year 4 student reported she realized things that were lacking in my record-keeping and that helped in the successive records. The audit training improved knowledge on the purpose of good record-keeping such as in medico-legal issues and easing treatment flow at the next visit as well as referral to another practitioner. A female Year 4 student commented that the audit exercise was a wake-up call to why record-keeping Table 2. Mean number of criteria met and standard deviation (SD) for each domain pre- and post-training Pre-Training Post-Training p-value Number of Criteria Met n (SD) n (SD) (<0.05) Personal Details (n=9) 8.72 (0.701) 8.65 (0.863) Medical History (n=3) 0.40 (0.990) 2.29 (1.202) Dental History (n=4) 0.80 (0.990) 3.00 (1.429) Extraoral Examination (n=5) 0.02 (0.141) 2.98 (2.188) Intraoral Examination (n=3) 1.24 (0.431) 1.54 (0.617) Investigations (n=1) 0.16 (0.370) 0.42 (0.498) Diagnosis (n=1) 0.38 (0.490) 0.81 (0.394) Treatment Plan (n=3) 1.76 (0.476) 1.96 (0.289) Procedures (n=2) 1.62 (0.490) 1.83 (0.519) Updated Records (n=1) 0.92 (0.274) 0.94 (0.245) Total (n=32) (2.334) (4.903) Table 3. Mean of criteria met and standard deviation (SD) before and after clinical audit comparing Year 4 and Year 5 Year 4 Year 5 Pre-Training Post-Training p-value Pre-Training Post-Training p-value Number of Criteria Met n (SD) n (SD) (<0.05) n (SD) n (SD) (<0.05) Personal Details (n=9) 8.84 (0.574) 8.81 (0.477) (0.857) 8.35 (1.272) Medical History (n=3) 0.50 (1.107) 2.42 (1.148) (2.060) (1.298) Dental History (n=4) 0.81 (1.03) 3.13 (1.310) (0.943) 2.76 (1.640) Extraoral Examination (n=5) 0.03 (0.177) 3.32 (2.104) (0.000 ) 2.35 (2.262) Intraoral Examination (n=3) 1.19 (0.397) 1.65 (0.608) (0.485) 1.35 (0.606) Investigations (n=1) 0.25 (0.440) 0.32 (0.475) (0.000) 0.59 (0.507) Diagnosis (n=1) 0.44 (0.504) 0.84 (0.374) (0.461) 0.76 (0.437) Treatment Plan (n=3) 1.78 (0.420) 2.03 (0.180) (0.428) 1.82 (0.393) Procedures (n=2) 1.59 (0.499) 1.90 (0.396) (0.485) 1.71 (0.686) Updated Records (n=1) 0.91 (0.296) 0.90 (0.301) (0.236) 1.00 (0.000) Total (n=32) (2.375) (4.331) (2.229) (5.562) February 2014 Journal of Dental Education 209

5 is so important to maintain a good communication between practitioners. A male Year 5 student noted realizing that every detail from the patients needs to be recorded. Good record-keeping is not only good for us for legal reasons, it also benefits the patients and upon referral to other doctors. Another female Year 4 student noted that she had learnt a way to improve quality of care. The students also expressed how they had changed their behavior in record-keeping after the audit training. Most agreed that the quality of recordkeeping had improved and become more standardized, systematic, and consistent. For example, a female Year 5 student commented, without the clinical audit, I would not have kept proper and detailed records. There is now a systematic and consistent way of keeping each patient s record. Before this we had our own different ways and notes weren t as complete as now, said another female Year 5 student. Yet another female Year 5 student noted that now she would keep more thorough patient records... previously, I did not routinely record all aspects of patient treatment (materials used, drugs prescribed) and investigations done. Although most students reported a positive experience from the audit training, they also commented on how the training could be improved. For example, more time was said to be needed for preparatory work: not enough time was given to us to prep for presentations, noted a male Year 4 student. Some thought that the timing of the training should be earlier in the course: it should be done when students first started treating patients, recommended one female Year 4 student. Others thought it should be at a less busy time of the semester, objecting to the fact that it had been scheduled at a peak period of the semester, noted another female Year 4 student. A female Year 5 student said it should include all the preclinical students so that they can gain the skill of proper record-keeping. Students also made suggestions for improving the details of the training process. For example, they expressed the need for more support and supervision during the training: A more structured and organized training session would be preferred with more guidance, said one female Year 4 student; supervisor/ lecturer should be there to assist and to make sure that the students do it accurately, noted another female Year 4 student; we were a little lost because we didn t exactly know what to do, a female Year 5 student pointed out; and a male Year 5 student said that we should have interactive session. Others pointed out that additional resources would be helpful: have more references or comparison to other universities, suggested a male Year 5 student; and articles that supervisors think are useful was recommended by another male Year 5 student. Some students said they needed support to make sense of the audit exercise: a male Year 5 student, for example, commented that the students do not know what were the reasons behind clinical audits and we thought it was a waste of time. Discussion The aim of this article is to report on the implementation of clinical audit training in an undergraduate curriculum and its effectiveness in changing clinical practice. The key findings from students feedback suggested that the clinical audit was useful in helping students identify their limitations in the audit topic of record-keeping, in helping students learn about record-keeping, and in helping students improve their record-keeping skill. The latter finding was corroborated by qualitative findings from the audit on students records of patients treated before and after the audit training. Suggestions were also offered by students on improving the effectiveness of the audit training. This study was unique as the clinical audit training was student-driven with active participation from the students. Also, this study compared the results between students from different years of study and focused on the presence of criteria without the use of CRABEL scoring as reported by Pessian and Beckett. 14 Our study highlighted that clinical audit was a useful tool for assessing one s performance in clinical practice such as record-keeping and can promote positive changes in clinical practice. The results showed students improvement in recordkeeping following clinical audit training. This was observed for the two different cohorts, providing further evidence that clinical audit can improve the accuracy in clinical record-keeping. 14,20 The benefits of clinical audit teaching for medical students have also been reported, 15 and increasingly clinical audit teaching is being reported. 13 The finding that clinical audit promotes positive change in clinical practice supports the ADEE s recommendation that clinical audit training be incorporated into the undergraduate curriculum. 12,13 The teaching of quality improvement 210 Journal of Dental Education Volume 78, Number 2

6 methods to prepare students for safe practice in the workplace is also recommended by the World Health Organization. 12,21 Clinical audit, as a quality improvement tool, can help to support this objective. In our study, there was significant improvement in students recording of the medical history, dental history, and extraoral findings due to the new policy of having the patient s entire information in OpenDent. As the medical and dental history are important in the patient s records, some authors have suggested that having an input box to prompt the user to record the necessary information would improve that aspect. 22 There was only a small increase in recording of soft tissue findings, but failure to record the information may not be indicative of failure to carry out procedures since there are many record deviations from normal. 23 Other efforts such as a yearly self-audit according to the agreed standards may raise clinical record-keeping standards. The qualitative feedback received from the students supported the results of the quantitative analyses. The students reported that they had improved their record-keeping performance against the set standards following the clinical audit training. Consistent with a previous report, 7 the clinical audit exercise highlighted deficiencies in practice when compared to set standards. This provided an opportunity for the students to reflect on the standards of their performance, an aspect of clinical audit that is recognized. 15,24 The students reported learning about the importance of record-keeping and its benefits for the practitioner and the patient. The clinical audit can therefore be regarded as a teaching tool that can enhance students knowledge of a particular topic. 25 These students suggested that training in the clinical audit of record-keeping should have been implemented earlier during the course when they first started treating patients. Although the students received teaching in record-keeping earlier in the course, the suggestion seemed to be that clinical audit would be a useful tool to enhance learning about record-keeping. The students highlighted some areas for improvement in the teaching of clinical audit, suggesting a positive attitude towards the value of audit training. Clinical audit training as a learning tool would therefore appear to be acceptable to students. Consequently, clinical audit training has been incorporated into the dental undergraduate curriculum at IMU so that Year 4 students will audit various clinical practice areas. Conclusion Patient safety and quality of care are issues at the forefront of health care provision and consequently should be embedded in the curriculum of health care education. The findings of this study support the use of clinical audit as a learning tool for record-keeping as well as for improving clinical practice. 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