Analysis of the quality of dental record completion in a teaching-clinic

Abstract

Introduction: The dental anamnesis form is an essential tool for diagnosing and treating oral conditions, enabling the accurate collection of data reported by the patient. Objectives: To evaluate the quality of dental records completed by students in a teaching clinic. Materials and Methods: This is a cross-sectional and descriptive study that analyzed records completed between 2018 and 2023 at the teaching clinic of the Faculty of Science and Technology of Janaúba (FACITEC), in Janaúba, Brazil. Records were selected through systematic probabilistic sampling. Two independent and previously trained examiners assessed the records dichotomously (adequate/inadequate). Simple frequencies (n) and percentages (%) were calculated through descriptive analysis, complemented by photographic records for qualitative analysis. Results: Approximately 46.7% of the records showed 6 to 10 items inadequately completed. A high prevalence of incomplete consent forms (58.9%) and the absence of comprehensive treatment plans (80%) was observed. Additionally, records filled out in pencil and radiographs improperly stored were identified. Conclusion: The rates of inadequate record completion are concerning, highlighting the need for institutional actions to train students to properly and thoroughly complete records, ensuring quality care and protecting patients' rights.