Resumo

MTHETHWA, SR  e  MATJILA, SA. Missing or incomplete dental records: prevalence at Medunsa Oral Health Centre. S. Afr. dent. j. [online]. 2019, vol.74, n.7, pp.383-388. ISSN 0375-1562.  http://dx.doi.org/10.17159/2519-0105/2019/v74no7a5.

INTRODUCTION: Incomplete or missing records compromise the validity and reliability of investigations. Aims and objectives: This study describes the extent of the problem of missing or incomplete records at Medunsa Oral Health Centre. Dental records of repeat patients who consulted during July 2017 were assessed for completeness. The proportion missing was determined. DESIGN: This was a retrospective, descriptive cross-sectional study in which existing dental records were reviewed. METHODS: A systematic random sample of 110 dental records of repeat patients who consulted at Medunsa Oral Health Centre during July 2017 was traced in records rooms. Eleven routine data items were selected for evaluation of completeness. A yes or no checkbox was ticked in Microsoft Excel software to indicate whether or not the information was entered in the record. RESULTS: A response rate of 79.1% was obtained. The first visit of 87.3% of patients occurred in the past six years. A scant 3.6% of the records were fully completed; half were less than 80% completed. Records of a third of patients who had visited the hospital for the first time in 2011 could not be found. CONCLUSIONS: The standard of record-keeping in this random sample falls far short of the HPCSA standard.

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