Instructions for completing the Soft Tissue Examination Audit
Aim: To ensure that all patients receive a regular, thorough examination of their intra-oral soft tissues as part of their oral assessment, and that this examination is accurately recorded in their dental records.
Step 1: Using the Round 1 Data Collection Sheet (STEADCR1), look at the dental records of the previous 50 patients who received an examination. For each patient, tick the box for each area of intra-oral soft tissue which is recorded as having been examined. If there is no record in the patient’s notes on the day of examination that the intra-oral soft tissues were checked, tick the ‘NO RECORD’ box. If it has been recorded that the soft tissues have been checked, but there is no record of the status individual areas (eg ‘soft tissues OK’), tick ‘AREAS NOT SPECIFIED’.
It would make collation of data easier if you could complete all Data Collection Sheets on your PC, so that you can UPLOAD THEM AS ATTACHMENTS.
N.B. - there is no need, for the purposes of this audit, to note any lesions which were recorded.
Step 2: Using the Data Summary Sheet (STEADSS), note the total number of patients in Round 1
§ who had each specified area of the intra-oral soft tissues examined
§ whose dental records had no specified areas of the intra-oral soft tissues recorded
§ whose dental records had no record of a soft tissue examination.
Calculate as a percentage the number of patients examined for each category, and enter these in the relevant boxes. This information can be used at the end of the audit to create graphs, which you can include within your final audit report.
Step 3: a) Read the specified sections of the following attached documents, which highlight the reasons why a thorough soft tissue examination is required, and the anatomical areas to be examined:
SIGN Guideline 90 1:
Section 1 (Introduction), pages 1-2
Section 2 (Presentation, Screening and Risk Factors), pages 3-5
Section 3.1 (Referral), page 6
Annex 3 (Diagrams of the Head & Neck), pages 74-75
SDCEP OHA&R Guidance 2:
Section 2.2.2 (medico legal-issues), pages 7-9
Section 2.2.3 (record keeping), pages 10-11
Section 4.2 (assessment of the Oral Mucosal Tissue), pages 16-17
Appendix 9 (Assessment of Oral Mucosal Tissue Recording Form), page 70
b) Use the attached Intra-Oral Soft Tissue Recording Form (STEARFP1 and STEARFP2) while carrying out oral mucosal examinations for all patients who attend for examination or routine treatment over the next month. The diagrams in SIGN 90 Annex 3 or SDCEP OHA&R Appendix 9 can also be used.
This is designed to ensure that all areas of the oral mucosa are examined, and findings recorded in the dental notes.
c) Reflect on any issues encountered while carrying out intra-oral soft tissue examinations. Discuss these with colleagues locally and consider ways of overcoming any difficulties encountered.
Step 4: Using the Round 2 Data Collection Sheet (STEADCR2), repeat Step 1 above for 50 patients for whom you carried out an intra-oral soft tissue examination since completing Step 3.
Step 5: Using the Data Summary Sheet (STEADSS), repeat Step 2 above for Round 2 data.
Step 6: Write a short report reflecting on your experience of conducting this audit. This should include:
§ reflection on the importance of regular, thorough examination of the intra-oral soft tissues for all patients
§ details of any barriers encountered in carrying out and recording a soft tissue examination for your patients.
§ ways in which you managed to overcome any barriers mentioned above.
References:
1. Scottish Intercollegiate Guidelines Network (SIGN), 2006. Diagnosis and management of head and neck cancer: a national clinical guideline. Edinburgh, SIGN. http://www.sign.ac.uk/pdf/sign90.pdf
2. Scottish Dental Clinical Effectiveness Programme (SDCEP), 2012. Oral Health Assessment & Review - Dental Clinical Guidance. Dundee, SDCEP. http://www.sdcep.org.uk/index.aspx?o=3079
Project created and made available to all Dentists in Scotland by:
Donald Macfarlane
Senior Dental Officer
Teach &Treat Dental Clinic
Northwest Kilmarnock Area Centre
September 2014