Audit in the Completeness of Orthodontic Clinical Photographic Records in Queen Elizabeth II Hospital, Sabah

Abstract Background: Complete orthodontic photograph documentation is essential for efficient healthcare delivery, litigation, and publication. A well-managed photographic documentation system ensures easy retrieval. Incidences of failure in orthodontic clinical photograph tracing in Queen Elizabeth II Hospital triggered the need to explore the underlying problems. Aims: This audit was conducted to evaluate if record-keeping of orthodontic photographs taken in Queen Elizabeth II Hospital, Sabah, achieved the gold standard. Settings and Design: The gold standard was that 100% of the cases should consist of a minimum number of photographs needed. Photographs should be taken at the two distinct stages of orthodontic treatment, which are the pretreatment stage and post-treatment stage. A minimum of nine photographs, four extra-oral and five intra-oral photographs, should be taken in each stage of the treatment. Materials and Methods: Photographs of patients who completed their orthodontic treatment in the second half of the years 2015 ( n = 68) and 2023 ( n = 41) were audited. Contributing factors of the shortfall were identified. Remedial actions were then implemented prior to re-audit in 2023. The results between these two years were compared. Results: In 2015, 22% of cases had the complete set of photographs. The shortfall was attributed to factors related to the individuals, team, technology, and environment. After remedial actions, record-keeping quality significantly improved to 71% in 2023 ( P < 0.05). Conclusions: The completeness of clinical photographic records has not reached the gold standard, highlighting areas for improvement. Regular audits and strategic actions are needed to meet this standard.