Documentation Standards in Oral and Maxillofacial Surgery Records at Secondary Hospitals in Kwara State

Accurate and comprehensive clinical documentation is a fundamental requirement for safe patient care, legal accountability, and quality assurance in oral and maxillofacial surgical practice. In secondary health facilities in Nigeria, documentation standards may vary significantly from one institution to another, with potential consequences for patient safety and continuity of care. This observational study assesses the completeness, accuracy, and consistency of oral surgical clinical records at seven secondary hospitals in Kwara State, North Central geopolitical zone. Using a 25-item clinical documentation audit tool adapted from the Medical Records Standards Committee of Nigeria, records of 320 oral surgical encounters from 2021 to 2023 were reviewed. Assessment domains include consent documentation, pre-operative examination findings, diagnosis clarity, treatment notes, postoperative instructions, and follow-up scheduling. Results reveal that consent documentation was complete in only 44% of reviewed records, and postoperative instructions were entirely absent in 28% of cases. Diagnosis was recorded using informal descriptors rather than standardized terminology in 62% of records. The study identifies significant documentation quality gaps at all participating facilities and recommends the adoption of standardized oral surgical record templates, staff training in medical documentation, and periodic clinical record audits as a hospital governance tool in Kwara State. Keywords: clinical documentation, oral surgery records, secondary hospitals, Kwara State, audit.