It Ain't What You Say …: Legibility and Clarity of Treatment Records

Smith, Joseph M.; Farrington, Clare

doi:10.12968/denu.2000.27.8.384

Cited by 4 publications

(8 citation statements)

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“…A study of the legibility of entries in over 900 handwritten dental records within a ninedentist practice in USA found that many records contained 'brief illegible graffiti which even the writer has trouble in deciphering at a subsequent visit'. 15 There was no uniformity in use of abbreviations within the practice.…”

Section: Discussionmentioning

confidence: 99%

Inadequate record keeping by dental practitioners

2015

Aust Dent J

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Section: Discussionmentioning

confidence: 99%

Inadequate record keeping by dental practitioners

2015

Aust Dent J

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“…Handwritten records have continuously been proven to be ineffective at capturing all the information required of them by assessors (2, 3, 7). Persian and Beckett (3) found even after a repeat audit, patient’s medical histories were not being checked at each visit; at best, the sample group achieved an 85% compliance rate.…”

Section: Discussionmentioning

confidence: 99%

“…Persian and Beckett (3) found even after a repeat audit, patient’s medical histories were not being checked at each visit; at best, the sample group achieved an 85% compliance rate. Smith and Farrington (7) carried out two audits of nine dentists, auditing dental record legibility. The range of legible records found by the first audit was between 24.2% and 100% with the second audit finding a range of 53% to 100%.…”

Section: Discussionmentioning

confidence: 99%

“…The current practice of keeping clinical records is moving from the traditional (handwritten) method to more contemporary (computer‐generated) methodologies, and with this change, debate has arisen as to which should be the method of choice in carrying out this essential requirement of a dental practice. Handwritten records have long been audited for their quality and content (2, 5–7), and it has been noted on more than one occasion that the standard of these records can be less than satisfactory (2, 8). A significant shortcoming of handwritten records has been found in the past.…”

Section: Introductionmentioning

confidence: 99%

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A comparison of computer‐ and hand‐generated clinical dental notes with statutory regulations in record keeping

McAndrew

Ban

Playle

2011

Eur J Dental Education

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Introduction: Dental patient records should be of high quality, contain information to allow for good continuity of care and clinical defence (should the need ever arise) and, ideally, facilitate clinical audit. Handwritten dental records have been assessed for their compliance to statutory regulations, but the same cannot be levelled at computer‐generated notes. This study aimed to compare and analyse the compliance of both methods of data recording with statutory regulations. Method: Fifty consecutive sets of handwritten notes and 50 sets of computer‐generated notes were audited for compliance with a number of legal requirements and desirable characteristics for dental records and the results compared. The standard set for compliance with all characteristics was 100%. Results: The computer‐generated notes satisfied the set standard for 8 of the 11 legal requirements and three of six desirable characteristics. The handwritten notes satisfied the set standard for 1 of 11 legal requirements and none of the desirable characteristics. A statistical difference (using a 95% confidence interval) between the two methods was observed in 5 of 11 legal characteristics and three of six desirable characteristics, all of which were in favour of computer‐generated notes. Conclusions: Within the limitations of this study, computer‐generated notes achieved a much higher compliance rate with the set parameters, making defence in cases of litigation, continuity of care and clinical audit easier and more efficient.

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“…The moment a clinician feels unable to express himself/herself on the CD and reaches for a pen, the CD is doomed. A print out must be available to place the patients’ records, preventing the clinician having to duplicate their records and the consequential failure of the project. The advantage of using a keyboard to input the data is the ability to read it. It has been shown (11) that despite meetings and audits seven out of the nine dentists’ handwriting fell below the agreed standard. For patients seen in the dental hospital by multiple dentists, the clinical records need to be a clear summary of what was seen and done, as opposed to ‘a brief illegible graffiti which even the writer has trouble in deciphering at the subsequent visit’ (11).…”

mentioning

confidence: 99%

The role for ‘reminders’ in dental traumatology: 4. The use of a computer database for recording dento‐alveolar trauma in comparison to unstructured and structured paper‐based methods

Day

Duggal

Kiefte

et al. 2006

Dental Traumatology

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The aims of this study were to investigate the effectiveness of a computer database (CD) developed for this study, a plain paper unstructured history (USH) and structured histories (SH) for the recording of important prognostic factors for simulated dento-alveolar trauma. Twelve vocational trainees, seven postgraduates in paediatric dentistry and 24 general dental practioners were randomly assigned to using USH, SH or CD. Each dentist visited a series of simulated trauma cases (with models, photos, radiographs and actors) and was asked to record important prognostic factors for each injury and make a diagnosis. There were a total of 243 dentist contacts with the trauma stations. The average percentage of important prognostic factors recorded per station was: USH 53%, SH 75.3% and CD 58.6%. SH was significantly better than the other two methods (P < 0.001, anova). Interestingly, those general dental practitioners (GDPs) who qualified prior to 1990 were significantly poorer at recording important prognostic information using CD. This effect was not obvious when using USH and SH. It was also seen that USH and SH were significantly better at helping clinicians reach a correct diagnosis as compared with CD (P < 0.001, chi-squared). A paper-based SH was the most effective method for collecting essential prognostic information for simulated trauma cases used in this study. At present, the introduction of our CD for recording of trauma is not justified without significant modification.

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It Ain't What You Say …: Legibility and Clarity of Treatment Records

Abstract: The content of treatment records is irrelevant if it cannot be understood. This is a report of a clinical audit project that aimed to assess the readability of records, and set standards to be maintained throughout the practice for handwriting and use of abbreviations.

Cited by 4 publications

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Inadequate record keeping by dental practitioners

Inadequate record keeping by dental practitioners

A comparison of computer‐ and hand‐generated clinical dental notes with statutory regulations in record keeping

The role for ‘reminders’ in dental traumatology: 4. The use of a computer database for recording dento‐alveolar trauma in comparison to unstructured and structured paper‐based methods

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