The Impact of Educational Interventions on Clinical Documentation Using Pretest-Posttest CRABEL Scores: A Single Group Quasi-Experimental Study among Dental Interns.

Abstract

Objective: Clinical documentation is essential for patient safety, legal protection, and continuity of care. Nevertheless, record-keeping skills are usually overlooked by most undergraduate dental programs. This study investigated the outcomes of a structured educational intervention by auditing the outpatient case records documentation by dental interns at a public university of Saudi.

Materials and methods: A quasi-experimental single-group pre-post-test study was conducted among dental interns in the form of a baseline (July-September 2024) and a follow-up (October-December 2024) audit. The educational intervention consisted of a group presentation, one-on-one instruction, and monthly review sessions. Clinical records were assessed using a modified CRABEL scoring system. Completeness of patient data, medical and dental history, examination results, treatment planning, and authentication were evaluated in the documentation.

Results: A total of 20 interns participated in the study, with an average of 367.8 clinical records reviewed each month. At the baseline audit (July-September, 2024), at least one essential component was missing from 78% of the records. Incomplete dental exams (46%), unsigned entries (42%), and missing medical histories (54%) were the most common deficiencies. At the re-audit, missing medical histories decreased to 16%, and unsigned entries decreased to 22%. A proportion of 53.4% of records had a baseline Crabel score below 70% (mean score = 56.31 ± 28.2). At the re-audit, the mean score increased to 85.47 ± 16.6. Records with a score ≥80% increased from a proportion of 21.6 to 84.6%, while those with a score <70% dropped to a proportion of 15.3%.

Conclusion: Documentation quality and record-keeping by dental interns can be greatly enhanced by focused educational interventions. Undergraduate dental programs that incorporate frequent audits and targeted training are expected to assist students in developing lifelong habits of accurate and responsible clinical documentation.