沙特阿拉伯塔伊夫市哈达武装部队医院心脏病患者牙科与医疗记录之间的差异。

Discrepancies between dental and medical records of cardiac patients in AlHada Armed Forces Hospital, Taif, Saudi Arabia.

作者信息

Al Hibshi Sana M, Al-Raddadi Rajaa M, Assery Mansour K

机构信息

Dentist, Health Care Quality Management Specialist, AI Hada Armed Force Hospital, Taif, Saudi Arabia.

Joint Program of Family and Community Medicine, Ministry of Health, Jeddah, Saudi Arabia.

出版信息

J Int Soc Prev Community Dent. 2016 Nov-Dec;6(6):568-574. doi: 10.4103/2231-0762.195511.

DOI:10.4103/2231-0762.195511

PMID:28032050

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC5184392/

Abstract

AIMS AND OBJECTIVES

This study aims to estimate the prevalence of medical information discrepancies between dental and medical records of cardiac patients at AlHada Armed Forces Hospital in Taif and to identify the factors contributing to these information discrepancies.

MATERIALS AND METHODS

The study applied a descriptive retrospective medical and dental records review of a stratified proportional sample of 289 cardiac patients, which was extracted from 1154 cardiac patients who visited both the cardiology and dental clinics at the AlHada Armed Forces Hospital between 2007 and June 2012. Data were analyzed using the Statistical Package for the Social Sciences version 19.

RESULTS

The main results of this study are the following: The mean and standard deviation of patient's age was 56 ± 16.9, female patients represented 47.8% of the study population. A total of 78.5% of dental records were documented by dental residents whereas 48.4% of the dentists had more than 6 years of experience. Two hundred and seventy-nine (96.5%) of the 289 dental records had medical information discrepancies compared to the corresponding medical records. One hundred percent of systemic lupus erythematosus and rheumatic fever cases were not documented in the dental records followed by 93% of medications, 92% of stroke, and 88.5% of hyperlipidemia, whereas the least prevalent were cardiac disease (26%) and diabetes mellitus (22.2%).

CONCLUSION

Approximately 75% of the patients who directly or indirectly accessed the dental services showed discrepancies. The researcher concludes that critical information gaps exist between dental and medical records that mostly attributed to system level problems. A well-established model for efficient communication among medical and dental care providers caring for cardiac patients does not appear to exist. The absence of such a model can threaten the overall health of patients.

摘要

目的

本研究旨在估算塔伊夫阿哈达武装部队医院心脏科患者的牙科与医疗记录之间医疗信息差异的患病率，并确定导致这些信息差异的因素。

材料与方法

该研究对289名心脏科患者的分层比例样本进行了描述性回顾性医疗和牙科记录审查，这些样本取自2007年至2012年6月期间在阿哈达武装部队医院心内科和牙科诊所就诊的1154名心脏科患者。使用社会科学统计软件包第19版进行数据分析。

结果

本研究的主要结果如下：患者年龄的平均值和标准差为56±16.9，女性患者占研究人群的47.8%。共有78.5%的牙科记录由牙科住院医生记录，而48.4%的牙医有超过6年的经验。与相应的医疗记录相比，289份牙科记录中有279份（96.5%）存在医疗信息差异。牙科记录中未记录系统性红斑狼疮和风湿热病例的比例为100%，其次是药物记录缺失93%、中风记录缺失92%、高脂血症记录缺失88.5%，而记录最少的是心脏病（26%）和糖尿病（22.2%）。