Comparative study of reviewing patient records: preliminary results

Objectives: To identify an effective method to extract the information content and format of the dental records maintained by general dentists.

Methods: Two trained dentists reviewed six dental patient records maintained by dental students from the School of Dental Medicine, University of Pittsburgh.The records were of active patients and at least two years old with minimum three treatment procedures. The contents and data fields of patient records were mapped to ‘The Dental Patient Record: Structure and Function Guidelines' recommended by American Dental Association in 1987 and to the ‘Baseline Dental Record' (BDR) developed in a previous study. The structure of BDR is based on the ANSI/ADA Specification No.1000: Standard Clinical Data Architecture for the Structure and Content of an Electronic Health Record.

Results: The nine Basic Components in the ADA guidelines included most of the Information Categories (approximately 23) required to be part of the dental record. However, these guidelines do not support patient specific information. The BDR on the other hand included 20 information categories that concentrated on the clinical component of dental records. It displayed sufficient level of granularity to review dental records and supported the extraction of data elements from a wide variety of dental record formats.

Conclusion: This study showed that mapping of patient information from dental records to the ADA guidelines was difficult when compared to the structured BDR. The ADA guidelines lack the intricate structure based on which the information content of the dental records could be designed. This study was successful in identifying a method to extract the information content of reviewed dental records and in establishing an effective method to identify new data elements that could be added to the dental record.

Use of BDR and new data elements such as Identification Data and Completion Notes will facilitate the development of information categories required for improving clinical documentation of patient records.