Accepted for/Published in: JMIR Medical Informatics
Date Submitted: Dec 17, 2018
Date Accepted: Mar 13, 2019
(closed for review but you can still tweet)
Completeness of Electronic Dental Records in a Student Clinic: Is There Room for Improvement?
ABSTRACT
Background:
A well designed, adequately documented and properly maintained patient record is an important tool for quality assurance and care continuity. Good clinical documentation skills are supposed to be a fundamental part of dental student training.
Objective:
The goal of this study was to assess completeness of electronic patient records in a student clinic.
Methods:
Completeness of patient records was assessed using comparative review of validated cases of alveolar osteitis (AO) treated between August 2011 and May 2017 in a student clinic. Based on literature review, population-based prevalence of nine most frequently mentioned symptoms, signs and treatment procedures of AO were identified. Completeness of AO records was assessed by comparison of population-based prevalence and frequency of corresponding items in the student documentation. To obtain all AO cases, we ran a query on the electronic dental record which included all cases with diagnostic code Z1820 or any variation of the phrases “dry socket” and “alveolar osteitis” in the notes. The resulted records were manually reviewed to definitively confirm AO and to extract all index items.
Results:
Overall, 296 definitive cases of AO were identified. Only 22% of cases contained a diagnostic code. Results of comparison of frequency of nine index categories in the validated AO cases from student clinic and population-based prevalence were as follows: severe pain - 94% vs. 100%; bare bone / missing blood clot – 27% vs. 74-100%; malodor – 7% vs. 33-50%; radiating pain to ear – 8% vs. 56%; lymphadenopathy – 1% vs. 9-11%; inflammation – 14% vs. 50-85%; debris – 12% vs. 87-89%; AO site noted – 96% vs. 100%; anesthesia during debridement – 77% vs. 100%.
Conclusions:
There was a significant discrepancy between index category frequency in AO cases documented by dental students and verified population-based prevalence reported in peer-reviewed literature. More attention to clinical documentation skills is warranted in dental student training.
Citation
