dental school, our observations were consistent with the conclusions of these other studies fundamental clinic entries that either impact directly on quality of care provided or serve as a surrogate for measuring quality of dental care (e.g., the patient’s dental diagnosis) were missing from many records. In a preliminary work in which we looked at clinical dental records at one U.S. Patient clinical information was reported to be absent anywhere from 9.4% to 87.1% of the time. 22 The solitary paper we found investigating the adequacy of clinical dental records revealed several documentation flaws in those records. 21 Here in the United States, very little attention has been paid to the topic. 16– 20 For example, in one study, completed medical histories were present in only 44.6% of the patient charts and periodontal screening had been recorded in only 20.7%. Studies conducted in Australia, the UK and Scandinavian countries show clinical dental record keeping practices that fall well below basic standards. Regardless of any true consensus on the ideal content of a ‘good’ dental record, patient care is clearly not served if practitioners and allied health professionals do a suboptimal job of documenting and maintaining records. And while there might be a general understanding about the components of an “ideal” record (examination findings, diagnoses and risk assessments, treatment and prevention plans, treatment notes, patient communications including informed consent and dissent, dental laboratory communications, pharmacy communications, provider identification, patient information, medical and dental histories, radiograph, medical laboratory results, communications with specialists and physicians, waivers and authorizations, photographs and study models), there is no clear guidance about how information ought to be represented, and how often this information ought to be updated. 5– 10Īlthough there are some published guidelines for content, quality and accessibility of dental records, most notably by the American Dental Association 11– 14 and the American Association of Pediatric Dentistry in 2012 15, it is not at all clear that most dentists and dental institutions are aware of, or have adopted these guidelines in everyday practice. Research consistently shows that these problems are pervasive, ongoing and occur in many patient care fields. 1– 4 However, these admirable goals for patient records may be thwarted by significant issues: a lack of universally accepted documentation standards, incomplete or inaccurate record-keeping practices, unfriendly EHR user interfaces, and a lack of easy and consistent access to patient records. Accurate and complete clinical dental records have the potential to serve a variety of important purposes they allow for effective communication between health care providers, enable quality of care assessments, provide a database for dental research, aid in the defense of malpractice claims, assist forensic identification of victims and, of course, optimize the safety and effectiveness of patient care.
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