Levitin Seth Aaron, Grbic John T, Finkelstein Joseph
Division of Foundational Sciences, Columbia University College of Dental Medicine, New York, NY, United States.
Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
JMIR Med Inform. 2019 Mar 21;7(1):e13008. doi: 10.2196/13008.
A well-designed, adequately documented, and properly maintained patient record is an important tool for quality assurance and care continuity. Good clinical documentation skills are supposed to be a fundamental part of dental student training.
The goal of this study was to assess the completeness of electronic patient records in a student clinic.
Completeness of patient records was assessed using comparative review of validated cases of alveolar osteitis treated between August 2011 and May 2017 in a student clinic at Columbia University College of Dental Medicine, New York, USA. Based on a literature review, population-based prevalence of nine most frequently mentioned symptoms, signs, and treatment procedures of alveolar osteitis was identified. Completeness of alveolar osteitis records was assessed by comparison of population-based prevalence and frequency of corresponding items in the student documentation. To obtain all alveolar osteitis cases, we ran a query on the electronic dental record, which included all cases with diagnostic code Z1820 or any variation of the phrases "dry socket" and "alveolar osteitis" in the notes. The resulting records were manually reviewed to definitively confirm alveolar osteitis and to extract all index items.
Overall, 296 definitive cases of alveolar osteitis were identified. Only 22% (64/296) of cases contained a diagnostic code. Comparison of the frequency of the nine index categories in the validated alveolar osteitis cases between the student clinic and the population showed the following results: severe pain: 94% (279/296) vs 100% (430/430); bare bone/missing blood clot: 27% (80/296) vs 74% (35/47) to 100% (329/329); malodor: 7% (22/296) vs 33%-50% (18/54); radiating pain to the ear: 8% (24/296) vs 56% (30/54); lymphadenopathy: 1% (3/296) vs 9% (5/54); inflammation: 14% (42/296) vs 50% (27/54); debris: 12% (36/296) vs 87% (47/54); alveolar osteitis site noted: 96% (283/296) vs 100% (430/430; accepted documentation requirement); and anesthesia during debridement: 77% (20/24) vs 100% (430/430; standard of anesthetization prior to debridement).
There was a significant discrepancy between the index category frequency in alveolar osteitis cases documented by dental students and in the population (reported in peer-reviewed literature). More attention to clinical documentation skills is warranted in dental student training.
一份精心设计、记录充分且维护妥善的患者记录是质量保证和护理连续性的重要工具。良好的临床记录技能理应是牙科学生培训的基本组成部分。
本研究的目的是评估学生诊所中电子患者记录的完整性。
通过对美国纽约哥伦比亚大学牙科学院学生诊所2011年8月至2017年5月间治疗的经证实的干槽症病例进行比较回顾，评估患者记录的完整性。基于文献综述，确定了干槽症最常提及的9种症状、体征和治疗程序的人群患病率。通过比较人群患病率与学生记录中相应项目的出现频率，评估干槽症记录的完整性。为获取所有干槽症病例，我们在电子牙科记录中进行了查询，该记录包括所有诊断代码为Z1820或病历中出现“干槽症”和“牙槽骨炎”短语任何变体的病例。对所得记录进行人工审核，以明确确认干槽症并提取所有索引项目。
总体而言，共确定了296例经证实的干槽症病例。只有22%（64/296）的病例包含诊断代码。学生诊所与人群中经证实的干槽症病例的9个索引类别的频率比较结果如下：剧痛：94%（279/296）对100%（430/430）；骨面暴露/血凝块缺失：27%（80/296）对74%（35/47）至100%（329/329）；恶臭：7%（22/296）对33%-50%（18/54）；耳部放射痛：8%（24/296）对56%（30/54）；淋巴结病：1%（3/296）对9%（5/54）；炎症：14%（42/296）对50%（27/54）；碎屑：12%（36/296）对87%（47/54）；记录了干槽症部位：96%（283/296）对100%（430/430；可接受的记录要求）；清创时麻醉：77%（20/24）对100%（430/430；清创前麻醉标准）。
牙科学生记录的干槽症病例的索引类别频率与人群（同行评审文献报道）之间存在显著差异。牙科学生培训中应更加注重临床记录技能。
