Perceptions of undergraduate dental students at Makerere College of Health Sciences, Kampala, Uganda towards patient record keeping

Abstract

BACKGROUND. The creating, maintenance and storage of patients’ medical records is an important competence for the professional training of a dental student. OBJECTIVE. Owing to the unsatisfactory state of dental records at the students’ clinic, the objective of this study was to obtain information from undergraduate dental students on the factors that affect this process and elicit recommendations for improvement. METHODS. This qualitative cross-sectional study used focus group discussions with 4th- and 5th-year dental students for data collection. Data were captured through a written transcript and an audio recorder. The data were transcribed and analysed manually through developing themes, which were compared with the literature and interpreted. RESULTS. Three themes emerged: (i) Poorly designed clerking forms. The clerking forms were deemed to have a poor design with inadequate space for clinical notes. It was recommended that they be redesigned. (ii) Inadequate storage space. Space for storing patient records was deemed inadequate and a referencing system for file retrieval was lacking. It was recommended that more space be allocated for storage, with a referencing system for easy file retrieval. (iii) Poor maintenance of records. Patients’ records, especially radiographs, were not well labelled and stored. It was recommended that drug envelopes be utilised to store radiographs. An electronic system was deemed the ultimate solution to this problem. CONCLUSION. The general perception was that the current paper-based record system at the clinic was unsatisfactory. Therefore, there is a need to improve the maintenance and storage of records, and to change to a more efficient electronic system. The students’ attitude towards record keeping was found to be questionable, with a need to be addressed as part of teaching and learning in the curriculum. Lecturers were deemed to have a bigger role to play in the record-keeping process.