Year : 2015

Volume : Volume 5

Issue : Issue 1

Address for correspondence :
Dr. Swati Saraswata Acharya.
swati.acharya.tmdc@gmail.com

Abstract

Aims: To determine whether consent for orthodontic treatment is routinely documented by all orthodontic clinicians within Institute of Dental Sciences and even to identify areas where the documentation of consent is inadequate. Materials and Methods: 100% of all patients undergoing orthodontic treatment will have either verbal or written consent fully documented within their clinical notes. While a consent form is not a legal requirement, our team advises that all patients undergoing orthodontic treatment sign a departmental consent form. The suggested gold standard was 100% of records should also have a consent form present. Results: The specific risks of orthodontic treatment recorded were further assessed. It was found clinicians performed the best in recording the potential risk of relapse to patients (78%), while they performed most poorly when mentioning to patients the likelihood of any pain during orthodontic treatment (14%). Discussion: The first audit cycle showed only 76% of patients had consent documented, improving to 92% in the second cycle. Where consent had not been recorded, this was commonest in transfer patients and multidisciplinary cases. Orthodontic treatment risks were recorded in only 60% initially, proving to 87% in the second cycle. Conclusion: The overall improvements in the standard of record keeping for consent are testament to the effectiveness of clinical audit. Documentation of consent improved from 76% to 92% as a result of modifications to the consent form (better layout, check boxes). Progress towards the 100% “gold standard” will continue.
Keywords: Audit , consent, orthodontic treatment, Retrospective.