Display options
Cite
Tokede O, Ramoni RB, Patton M, et al. Clinical documentation of dental care in an era of electronic health record use. J Evid Based Dent Pract. 2016;16(3):154-160doi: 10.1016/j.jebdp.2016.07.001.
Tokede, O., Ramoni, R. B., Patton, M., Da Silva, J. D., & Kalenderian, E. (2016). Clinical documentation of dental care in an era of electronic health record use. The journal of evidence-based dental practice, 16(3), 154-160. https://doi.org/10.1016/j.jebdp.2016.07.001
Tokede, Oluwabunmi, et al. "Clinical documentation of dental care in an era of electronic health record use." The journal of evidence-based dental practice vol. 16,3 (2016): 154-160. doi: https://doi.org/10.1016/j.jebdp.2016.07.001
Tokede O, Ramoni RB, Patton M, Da Silva JD, Kalenderian E. Clinical documentation of dental care in an era of electronic health record use. J Evid Based Dent Pract. 2016 Sep;16(3):154-160. doi: 10.1016/j.jebdp.2016.07.001. Epub 2016 Jul 21. PMID: 27855830; PMCID: PMC5119920.
Copy Download .nbib Format: NLM
Share it on

J Evid Based Dent Pract. 2016 Sep;16(3):154-160. doi: 10.1016/j.jebdp.2016.07.001. Epub 2016 Jul 21.

Clinical documentation of dental care in an era of electronic health record use.

The journal of evidence-based dental practice

Oluwabunmi Tokede, Rachel B Ramoni, Michael Patton, John D Da Silva, Elsbeth Kalenderian

Affiliations

  1. BDS, MPH, Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, MA, USA. Electronic address: [email protected].
  2. DDS, ScD, Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, MA, USA.
  3. MA, DMD Student, Boston University, Henry M. Goldman School of Dental Medicine, Boston, MA, USA.
  4. DMD, MPH, ScM, Department of Restorative Dentistry and Biomaterials Sciences, Harvard School of Dental Medicine, Boston, MA, USA.
  5. DDS, MPH, PhD, Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, MA, USA.

PMID: 27855830 PMCID: PMC5119920 DOI: 10.1016/j.jebdp.2016.07.001

Abstract

BACKGROUND: Although complete and accurate clinical records do not guarantee the provision of excellent dental care, they do provide an opportunity to evaluate the quality of care provided. However, a lack of universally accepted documentation standards, incomplete record-keeping practices, and unfriendly electronic health care record (EHR) user interfaces are factors that have allowed for persistent poor dental patient record keeping.

METHODS: Using 2 different methods-a validated survey, and a 2-round Delphi process-involving 2 appropriately different sets of participants, we explored what a dental clinical record should contain and the frequency of update of each clinical entry.

RESULTS: For both the closed-ended survey questions and the open-ended Delphi process questions, respondents had a significant degree of agreement on the "clinical entry" components of an adequate clinical record. There was, however, variance on how frequently each of those clinical entries should be updated.

SUMMARY: Dental providers agree that complete and accurate record keeping is essential and that items such as histories, examination findings, diagnosis, radiographs, treatment plans, consents, and clinic notes should be documented. There, however, does not seem to be universal agreement how frequently such items should be recorded.

CLINICAL IMPLICATIONS: As the dental profession moves towards prevalent use of electronic health care records, the issue of standardization and interoperability becomes ever more pressing. Settling issues of standardization, including record documentation, must begin with guideline-creating dental professional bodies, who need to clearly define and disseminate what these standards should be and everyday dentists who will ultimately ensure that these standards are met and kept.

Copyright © 2016 Elsevier Inc. All rights reserved.

Keywords: Dental record; Dentistry; Documentation; Record keeping; Standardization

References

  1. Community Dent Oral Epidemiol. 1992 Apr;20(2):102-5 - PubMed
  2. J Forensic Dent Sci. 2010 Jan;2(1):5-10 - PubMed
  3. J Am Med Inform Assoc. 2013 Jan 1;20(1):134-40 - PubMed
  4. Methods Inf Med. 1986 Jul;25(3):151-7 - PubMed
  5. Acta Odontol Scand. 1998 Oct;56(5):288-92 - PubMed
  6. J Am Med Inform Assoc. 2005 Jan-Feb;12(1):8-12 - PubMed
  7. Dent Clin North Am. 1985 Jul;29(3):483-96 - PubMed
  8. Med Teach. 2005 Nov;27(7):639-43 - PubMed
  9. J Dent Hyg. 2000 Fall;74(4):297-306 - PubMed
  10. Aust Dent J. 1994 Feb;39(1):45-9 - PubMed
  11. Intensive Care Med. 2001 Jan;27(1):122-30 - PubMed
  12. J Am Med Inform Assoc. 2014 Nov-Dec;21(6):1136-40 - PubMed
  13. Br Dent J. 2004 Dec 11;197(11):703-5 - PubMed
  14. J Dent Educ. 2011 Jan;75(1):68-76 - PubMed
  15. J Grad Med Educ. 2013 Dec;5(4):600-4 - PubMed
  16. Stud Health Technol Inform. 2004;107(Pt 1):683-7 - PubMed
  17. J Biomed Inform. 2013 Oct;46(5):830-6 - PubMed
  18. Pediatr Dent. 2012 Sep-Oct;34(5):181-8 - PubMed
  19. J Am Med Inform Assoc. 2004 Mar-Apr;11(2):104-12 - PubMed
  20. J Am Med Inform Assoc. 2006 May-Jun;13(3):344-52 - PubMed
  21. Swed Dent J. 1994;18(6):233-41 - PubMed
  22. Br Dent J. 2001 Oct 27;191(8):436-41 - PubMed

MeSH terms

Publication Types

Grant support