Completeness of Electronic Dental Records in a Student Clinic: Retrospective Analysis

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 the 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 treated between August 2011 and May 2017 in a student clinic at Columbia University College of Dental Medicine, New York, USA. Based on a literature review, population-based prevalence of nine most frequently mentioned symptoms, signs, and treatment procedures of alveolar osteitis was identified. Completeness of alveolar osteitis records was assessed by comparison of population-based prevalence and frequency of corresponding items in the student documentation. To obtain all alveolar osteitis 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 resulting records were manually reviewed to definitively confirm alveolar osteitis and to extract all index items. Results Overall, 296 definitive cases of alveolar osteitis were identified. Only 22% (64/296) of cases contained a diagnostic code. Comparison of the frequency of the nine index categories in the validated alveolar osteitis cases between the student clinic and the population showed the following results: severe pain: 94% (279/296) vs 100% (430/430); bare bone/missing blood clot: 27% (80/296) vs 74% (35/47) to 100% (329/329); malodor: 7% (22/296) vs 33%-50% (18/54); radiating pain to the ear: 8% (24/296) vs 56% (30/54); lymphadenopathy: 1% (3/296) vs 9% (5/54); inflammation: 14% (42/296) vs 50% (27/54); debris: 12% (36/296) vs 87% (47/54); alveolar osteitis site noted: 96% (283/296) vs 100% (430/430; accepted documentation requirement); and anesthesia during debridement: 77% (20/24) vs 100% (430/430; standard of anesthetization prior to debridement). Conclusions There was a significant discrepancy between the index category frequency in alveolar osteitis cases documented by dental students and in the population (reported in peer-reviewed literature). More attention to clinical documentation skills is warranted in dental student training.

Using big data to promote precision oral health in the context of a learning healthcare system

“…Data from Medicaid claims, private insurance claims, emergency department records, and many other primary data sources have been used in oral health data analysis studies across the globe . Recent studies identified potential limitations of using EHR data generated solely by dental schools as they may represent a biased patient sample . Similarly, administrative and claims records such as Medicaid data represent a very valuable resource use of which requires understanding of its strengths and limitations .…”

“…33,37,43 Recent studies identified potential limitations of using EHR data generated solely by dental schools as they may represent a biased patient sample. 59 Similarly, administrative and claims records such as Medicaid data represent a very valuable resource use of which requires understanding of its strengths and limitations. 60 Future research should capitalize on growing availability of integrated comprehensive data sets representing all facets of oral health.…”

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Leveraging Electronic Dental Record Data for Clinical Research in the National Dental PBRN Practices

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