An audit of the quality of orthodontic consent form completion among IIUM postgraduate residents: first-cycle findings

Abstract

Informed consent (IC) is both a legal and ethical requirement in clinical practice and holds particular importance in orthodontics due to the long-term nature of treatment. Comprehensive documentation of the consent process supports patient autonomy, enhances communication, and ensures professional accountability. This audit aimed to assess the quality and completeness of informed consent documentation within the Doctor in Orthodontics (DrOrth) postgraduate programme at the International Islamic University Malaysia (IIUM), as part of a Continuous Quality Improvement (CQI) initiative. A retrospective audit was conducted on 360 randomly selected patient records, managed by eight postgraduate residents between February and June 2024. Nine target criteria were assessed based on the Malaysian Medical Council’s Guidelines for Consent for Treatment, with each criterion benchmarked against a 100% compliance standard. The sample represented approximately 45% of the total eligible patient population. All active orthodontic cases under postgraduate care were included. While the presence of consent forms was documented in 96.1% of cases, overall adherence to the nine target criteria varied between 84.7% and 96.1%. The highest compliance was observed for patient/guardian signatures and clinician documentation. However, the ‘Benefits and Risks’ section showed the lowest completion rate (84.7%), indicating a potential gap in documenting the treatment implications. Additionally, good effort found in 23.3% of forms which included documentation of ‘Additional Specific Risks’. Consent forms were present in the majority of cases, the audit identified areas requiring improvement in the completeness of documentation. Targeted improvements, particularly in risks documentation, are recommended to enhance compliance with informed consent standards in orthodontic care.