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AN AUDIT ON THE COMPLETENESS OF CLINICAL PHOTOGRAPHS AT ORTHODONTIC
DEPARTMENT, KOTA KINABALU, SABAH
NMRR-19-1012-47637

Har WY, Lynnora PM

Introduction: Clinical photographs remain the most invaluable, practical, conventional,
quick and simple method in providing information. Complete documentation is therefore
essential for efficient healthcare delivery and medico-legal records. Objective: To assess
the availability and completeness of clinical photographs in order to evaluate the quality of
record-keeping in the Orthodontic Department, Kota Kinabalu, Sabah. Materials and
Methods: This cross-sectional study involving patients who completed their active
orthodontic treatment in this department between June 2015 and December 2015. A
complete set of clinical photographs required in each patient’s record consisted of a
minimum of 18 photographs. This included pre-treatment and post-treatment
photographs in which each contained 4 extra-oral and 5 intra-oral photographs.
Photographs were traced back through a computer database. Findings were recorded in a
data collection form and were analysed descriptively. The gold standard of this audit was
that 100% of patients should comply with the minimum number of photographs needed.
Results: Of 68 patients reviewed, only 22% (n = 15) had a complete set of clinical
photographs. Conclusion: The gold standard was not achieved. The second cycle of the
audit would be done after implementation of strategies to improve the storage system in
the Orthodontic Department, Kota Kinabalu.

Presented at the Orthodontic Department, Hospital Queen Elizabeth II on 15 January 2021.
th
Dr Har Wai Yan
Dr Lynnora Patrik Majawit
Orthodontic Specialist Clinic
Queen Elizabeth II Hospital
Kota Kinabalu Sabah

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