Frequency of missing data in clinical records in pediatric dentistry: a descriptive study

Abstract

The aim of the present study was to investigate the frequency of missing data on routine dental care appointments and restorative procedures from the clinical records of children treated at a pediatric dental clinic. A descriptive retrospective study was conducted involving the clinical records of children three to 12 years of age treated only with restorations. The inclusion criteria were clinical records from the past 10 years of children with at least one restored tooth. Data collection was performed by a trained examiner who extracted information from the clinical records on appointments for routine dental care and restorative procedures. The frequency of missing data on clinical records was submitted to descriptive analysis. Among the 249 clinical records analyzed, boys accounted for little more than half (54.2%) and mean patient age was 6.9± 1.8 years. Ninety-four of the 249 clinical records were of appointments for routine dental care. Missing data were found for the gingival bleeding index (18.1%), visible plaque index (22.3%) and dietary logs (74.5%). Forty-seven children were submitted to a total of 618 restorative procedures. Information was missing on the type of restorative material (5%), brand of the material used (65.2%), the type of isolation (50.8%) and whether pulp capping was performed (75.9%). The percentage of missing data from clinical records was substantial, demonstrating that important information is not recorded during routine dental care or restorative procedures.

Qualidade de preenchimento de prontuários clínicos por estudantes de uma Faculdade de Odontologia brasileira

“…A manutenção dos prontuários odontológicos é necessária para garantir o fluxo adequado e sistemático do tratamento dos pacientes, contribuindo para a melhoria dos serviços prestados à comunidade. Também é essencial por razões médico-legais 4 , pois a documentação inadequada do atendimento odontológico impacta desfavoravelmente o cirurgiãodentista em processos jurídicos 1,5,[16][17][18] . Além disso, o preenchimento e guarda adequados de prontuários odontológicos podem subsidiar o desenvolvimento de pesquisas, trazendo importante contribuição para o ensino de graduação e pósgraduação.…”