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    ODONTOLOGIA: Adequacy of dental records in clinical practice- a survey of dentist

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    Adequacy of Dental Records in Clinical Practice- A Survey of Dentists.

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    ODONTOLOGIA: Adequacy of dental records in clinical practice- a survey of dentist

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    © All Rights Reserved
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    Adequacy of Dental Records in Clinical Practice - A Survey of Dentists.

    Uploaded by

    mcinserry
    ODONTOLOGIA: Adequacy of dental records in clinical practice- a survey of dentist

    Copyright:

    © All Rights Reserved
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    Adequacy of Dental Records in Clinical Practice: A Survey of Dentists y 27.8. Osborn, ROH, MA; Jil L. Stotenberg, ADH, MA; Kathleen J. Newell, RDH, PhD, ( ’ and Scott C. Osborn, DDS Q 8 $ Introduction 55 $8 Most dental health care ® < providers would agree that the eee sit “ Qn Q patient record is an essential com- | anual a polar end 2 gs QW ponent of dental and dental hygiene a = SY practice. Since it contains continu &y us documentation of patient oral conditions and treatment, the Bg record isthe primary tool used in '§ the evaluation of patent care. Such evaluation is useful, and necessary, 2 tgqacor i 7 jn Lvs rd Tee cute a random sample of 750 \ Minnesota dnt, Hemindsrposiarde were set wo weeks eer th LS initial survey mailing. A third mailing to nonrespondents, including cover Tor several reasons. Fir. the use| atari pleas quccionnaite was conducted three weak iter OF x of patient records jn auditing pro- | fg Telumed, 63% (N=475) were analyzed. Data analyses, cedures for quality careassessmeri, [SH MRI anetecis of c-SGhave, Were eohdoeey feta Fis teen wel documened in senwell documented mfr | Statview and SPSS. Tratirg The basse premise & B65) circcroniie moda ioiaes Soe hata god thorogh record ks P — format, 44% (N=208) used multiple forms fled in hese ing system allows appropriate cv:l- MMAR aRAI tba Meniess eeneping, 806 (estat fl tle uation of care and a poor one. | qggummentation Wes adequate without comparison to any speciied cr while not necessarily indicating © | figs Hole, statistically significant differences oocurred between \ » {> lack of quality care, makes it diff ceplion of record adequacy and the actual presence or Ee acts evens i a Ropers ol cod gor Bl 8 care process. A mutual relationship | fo ss absent 9.4%, 10 87.1% of Tete exists between the adequacy of record keeping and the adequacy ‘of patient care," Second, legal concerns are a Siapot comet prace aT pam cert reve OST? Sere eeepc wee eee Tn complete Fecords. are sential m_the practitioner's eae TR pony TorTEonsirating the provision of has been published on evaluating yo! record adequacy by comparing ‘quality care rests with the health the adequacy of records used by -~ self-reported contents of patient ‘care provider'** Accountability to dentists and dental hygienists in 9) records used by dentists in clinical nts, to third-party payers, and practice. Putient records are used in, ¥ practice 10 recommended guide- mental agencies is an lines published by the American task without good Dental Association (ADA). While “— both dentists and dental hygienists ‘a responsibility for maintain- lists wre selected as survey sub- jects in this study since, in most & instances they have deterninedthe © type of econt keeping system used © in the practice, & Literature Review “ The rep between they: R eeetrenl moras ‘onto and he aby tocnalu $3 ate the patient care process has © Ses deseribed inthe quality asur~ ' ance literature for some time. masa Insts fg and Orlow sey Thane Tatar eo ae a ys operates {0 See ee OY Bainatentaam Soertieamtecietamm Q "Raa seid SSoscscce Sa ESET Taro Fired Sinilar view onthe aby of dental records to completely dlcument the proces and outcome of dental care The assumption is that patent care aTEAT OSA, + Sate her ths asREnT Tora a +S The need Tr thorough paint'S FRc documentation wes the pe eee ee ees Se AMP were not published, they found the records surveyed gener impossible to evaluat meta tunless adequate records are used 0 The association's quality assurarige ee nutied a | | fon, characterisnes, format a - Baie oa ye : Epa pe TY eee aes ftinee Tor taproving Tet aaa Thattempung tine ‘and eval- aE Satispescy of recood keep. ing, several authors and dental organizations have identified criti- ‘eal components to be included in _ record documentation. Bailit et al. ed criteria and standards for each of the four primary record ‘components; history and examina- tion, diagnosis (although not nec- essarily designated on particular @) lines of the dental ReG5RE" Legis- , lation introduced in 1997 by the sola State Board of Dentistry form within the record), irsaiment required minimum record keeping plan (elicited primarily from pro- gress notes and patient examina: tion), and treatment (assessment of TOO eC TET A) Rea COMPOTEMI TETRA assess ‘ment information (initial database, database update), diagnosis (prob- lems identified), treatment plan eA of intended procedures, sequenc- ing), and patient treatment (pro: gress notes indicating treatmen provided). Ray-and Staffa ientitied the © cotpOREN OT IEA TOOTS. fant neck aT TEL omarting consisting of diagram: eS ‘BoeMeL Utara Tare imeem ear or © “GaT PEER inthe record, treatment plan (otlined diagrammatically fo a treatment needed and treatment completed), and noes on treatment performed at each visit. Ober bbreckling stated that records should, ‘clade Cetared ocumentanor oT A aetna aT Bi. denat sto Sf xem | istory. clinical exam rogress notes, completion Roles, ee ictomatice acer ea forcing" Laney presented somiar-cntera ant furdelines Tor developmag adequate e ree gencr- © Seconds mening om ponET ally lacked Sunardaation and unig) SRUER- aera Te as radiographic _criterni, formity, They also greed that iti, "Heeordimg patient prescnpuons afd dl dental organizations also have developed standards of care to ensure record adequacy “These standards provide guidelines to practitioners for improving their record documentation, in order to ‘comply with professional and legal requirements, Schoen, et al.,estab- lished Guidelines for Criteria and Standards of Acceptable Quality General Dental Practice, which contains a section on record keep- ing,'In 1987, the American Dental Association published its recom= ‘mendations for structure and guide-. standards for patient records.” Thi record keeping rule outlined the {Y basic components of the patient cal quality of dental care record and defined aspects within each component necessary for inclusion in the documentation of care. The ultimate goal of these indards was to help practitioners achieve the level of documentation necessary 10 accurately reflect the quality of patient care delivered. In spite of the extensive litera- \ ture supporting the need for quality « patient records, few studies have S been published on the adequacy of dental records setally used in ein ical practice. Gill and Howard pro- Posed use ofa simplified checklist to ascertain the completeness and aceuraeY of record documentation. = They studied several aspects of record keeping: the completeness historical and demographic data, the aceuracy of detail in deserib- ing procedures performed, ‘aii fe and appropriateness of the treatment plan, documentation ‘of medications, and the outcome of treatment. The findings of 24 record audits revealed that 75% of the records contained one or more errors such as inappropriate med: ication prescriptions written for patients, legibility problems, isfad- equate information on the amount or type of anesthetic used, and doc umentation of significant medical conditions after treatment had begun. The authors concluded that while quality of care was not always inadequate in the popula- tion studied, the documentation made it difficult to be certain Minden and Fast evaluated the adequacy otrecord docum 3 a He ke 385 valuationyperiodontal eyaluaion,’ allow for nonrespondents or recent © eXample, subjects were asked in besiment plan, documented récall career changes, such as unemaloy this survey if the patient’s medical and radiology. While most dentists ment or retirement. story and informed consent were submitted forms highlighting these ‘The data collection instrumet te documents in the record. * areas of documentation, the authors “consisted of 72 items designed to Y While items related to record con- ‘idemifiedspecitic patient informa- SY assess dentists’ perception of the «Q tent were based on ADA’s guidle- tion missing within each category. %X adequacy’of their dental records lines. they were not identified as pee ere ae oar ae Gator Gar Gteanepienet oats \ recur (ermal Le, sage page v. § encing subjects reponaes: Subjects Seaport © rtulcle forma) and coowen (hc. wore asked to indleate wheter or Biome meta Matar wth apc ilomatonclete) The § wx speci paentnfoaton nas Se We Patient Record: Structa#é ~ consistently collected. ee ee Oe arco Serena Metnertnnisee the Was Used NcoM 4 10 dentists in clinical practice and ; ee eee errr arenedingty eeteey ae eee se gun cover letter, and self-addressed) eed eee ee eter gc v2 » eee Tear rm zd fois Olden Subjects were Se eae ie recor, TENT TECO assured that responses would g \S aA te 60 x = Alea par veya ered by Sieigcieaiaieas \gMeMnaieengiiegeete sumber for follow-up to non _ can eee Tego air respondems as ceded Dentidas — Garments Simeng TERE for extab- Tine guity raventiecerisccig, [Basieeomponente of @ dental pation record should include there is little evidence in the liter- . ‘ture of using them to assess the | Identification data: patient registration information; personal aUequacy of records used in dental S | information; who to contact in case of emergency QD practice. This study sas conducted) | Medical history": comprehensive witen evaluation ofthe pation’s 5° todetermine dentists tong. | medical history; medications and their dosage; allergies; relevant ax: alata er eco «| fal sees SS Te aton RSS IDE TEER! S| erat pstory: che! complaint past dental experiences; dental phobias. 9 gontenis of dental records used By eee! iy (O compre tie selrreparet coreg | Clinical examination: charting of presentmissing teeth; restorations “BE ena cor wh gue Tecordspwiy guideline-

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