Clinical Audit on Evaluating the Completeness of Standard Pre-Operative Preparations for Paediatric Patients Receiving Dental Procedures under General Anaesthesia

Abstract Objective: This clinical audit aims to enhance the quality of care for paediatric patients undergoing dental procedures under general anaesthesia (GA) by evaluating the completeness of standard pre-operative preparations at the Department of Paediatric Dentistry, Hospital Teluk Intan. Materials and Methods: Conducted from August 2022 to December 2022, this audit involved a retrospective review of patient records from two cycles: March 2022 to May 2022 (Cycle 1) and September 2022 to December 2022 (Cycle 2). Data were collected using a standardised checklist that covered demographic information, pre-admission instructions, proposed treatment type, consent, and medications. The completeness of documentation was assessed against the Safe Surgery Save Lives guidelines by the Ministry of Health Malaysia, with a target of 95%. Results: In Cycle 1, 30 patient records were reviewed, showing a mean completeness of 90%. Demographic information, proposed treatment and consent were fully documented (100%), while pre-admission instructions and medications had lower completeness (75.8% and 96.5%, respectively). Following the implementation of a standardised checklist, 24 records were reviewed in Cycle 2, achieving and achieved 100% completeness across all variables. Conclusion: The introduction of a standardised checklist significantly improved the completeness of pre-operative preparations for paediatric dental patients under GA. This audit highlights the importance of standardised protocols in enhancing documentation practices, minimising medical errors and improving patient outcomes.