175 - Standardizing Clinical Documentation In Pediatric Dentistry

Abstract: Standardizing Clinical Documentation In Pediatric Dentistry
Bailey J, Followell T, Viera L
University of Louisville, Louisville, KY

Purpose: Despite established recordkeeping guidelines, incomplete and inconsistent clinical documentation limit optimal care in pediatric dentistry This quality improvement project aims to improve documentation completeness and consistency through implementation of a standardized charting template aligned with pediatric dentistry recordkeeping standards.

Methods: This prospective quality improvement initiative was conducted over a 3-month period in a university-based pediatric dental clinic. Baseline documentation completeness was assessed through audit of 30 de-identified charts representing commonly completed procedures, including comprehensive, periodic, and limited oral evaluations, extractions, stainless steel crowns with or without pulp therapy, nitrous oxide/oxygen analgesia, and fluoride varnish application. Charts were evaluated for the presence of 15 essential documentation elements derived from professional recordkeeping guidelines. Baseline resident and faculty surveys assessed documentation clarity, workflow burden, and perceived deficiencies. A standardized electronic documentation template incorporating required elements were then be developed and implemented. Post-implementation chart audits and surveys were conducted using identical methods.

Results: This project is ongoing.

Conclusions: Implementation of a standardized, guideline-based documentation template is anticipated to improve the completeness and consistency of pediatric dental records across high-volume clinical procedures. This initiative is expected to increase documentation completeness, reduce variability across providers, and improve consistency in recording behavior assessment, pain evaluation, caries risk assessment, radiographic interpretation, consent documentation, and follow-up planning without increasing documentation burden. If successful, this initiative may provide a sustainable framework for documentation quality improvement within pediatric dental residency programs.







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