Evaluation of Dental Patient Record’s Content: Preliminary Results

Objective was to evaluate the content of the patient’s dental record. Ten records of active patients, at least two years old with minimum three treatment procedures, maintained at the University of Pittsburgh’s School of Dental Medicine were reviewed. Two dentists trained in biomedical informatics compared the contents of the records to a Baseline Dental record (BDR) developed in an earlier study. Total of 187 data-fields were identified from the dental record forms and an average of 137 data-fields were documented. 66 data-fields (35%) were classified as administrative and 121 (65%) as clinical. Out of 121 clinical fields, only 68 data-fields could be cross-mapped to the BDR. The remaining 53 data-fields were updated to the BDR as explicit datafields. 17 data-fields were defined and updated to the BDR as implicit data-fields. Absence of appropriate data-fields in the dental record contributes to the incomplete documentation of patient information by the dentists.