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牙科记录保存:波斯尼亚和黑塞哥维那联邦的实践。

Dental Recordkeeping: Practice in Federation of Bosnia and Herzegovina.

作者信息

Cilovic-Lagarija Seila, Hasanica Nino, Begovic Elma Sokic, Pestek Adisa, Radojicic Milan, Ramic-Catak Aida, Tukulija Sanela, Selimovic-Dragas Mediha

机构信息

Institute for Public Health FB&H, Sarajevo, Sarajevo, Bosnia and Herzegovina.

Institute for Health and Food Safety Zenica, Institute for Public Health, Zenica, Bosnia and Herzegovina.

出版信息

Acta Inform Med. 2021 Sep;29(3):205-209. doi: 10.5455/aim.2021.29.205-209.

DOI:10.5455/aim.2021.29.205-209
PMID:34759461
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC8563040/
Abstract

BACKGROUND

Dental documentation which includes main information about a patient and dental treatment provided is a very important asset of each dental office.

OBJECTIVE

This research aims to analyze the way of fulfilling and keeping mandatory dental records and periodic reporting forms by doctors of dental medicine in the Federation of Bosnia and Herzegovina (FB&H).

METHODS

The study was observational with a cross-sectional design using a questionnaire as a study tool. The questionnaire was distributed electronically to the participants working in public health care facilities and private practice.

RESULTS

A total of 426 Doctors of Dental Medicine (DDM) participated in the study, of whom 58.7% of respondents were employed in dental offices in the public health sector and 41.3% in dental offices in the private health sector. Dental records are filled out only manually by 53.5% of respondents, while 9.4% fill out the records only electronically, while 37.1% of respondents fill out records both manually and electronically. The manner of keeping dental documentation between respondents employed in dental offices in the public health sector and dental offices in the private health sector differs significantly (p<0.05). Almost all respondents understand the purpose and significance of keeping dental records.

CONCLUSION

This paper points out that good dental records are of great importance as they allow monitoring the quality of services provided to patients for a longer period.

摘要

背景

包含患者主要信息及所接受牙科治疗的牙科文档是每个牙科诊所的一项非常重要的资产。

目的

本研究旨在分析波斯尼亚和黑塞哥维那联邦(波黑联邦)牙科医生填写和保存强制性牙科记录及定期报告表格的方式。

方法

本研究采用横断面设计进行观察性研究,使用问卷作为研究工具。问卷通过电子方式分发给在公共卫生保健机构和私人诊所工作的参与者。

结果

共有426名牙科医生参与了本研究,其中58.7%的受访者受雇于公共卫生部门的牙科诊所,41.3%受雇于私人卫生部门的牙科诊所。53.5%的受访者仅手动填写牙科记录,9.4%仅通过电子方式填写记录,而37.1%的受访者同时采用手动和电子方式填写记录。公共卫生部门牙科诊所的受访者与私人卫生部门牙科诊所的受访者在保存牙科文档的方式上存在显著差异(p<0.05)。几乎所有受访者都理解保存牙科记录的目的和意义。

结论

本文指出,良好的牙科记录非常重要,因为它们有助于长期监测为患者提供的服务质量。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/fbe9/8563040/9541d5dacb98/AIM-29-205-g004.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/fbe9/8563040/f77fca344873/AIM-29-205-g001.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/fbe9/8563040/f689194fa411/AIM-29-205-g002.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/fbe9/8563040/c458efce9dba/AIM-29-205-g003.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/fbe9/8563040/9541d5dacb98/AIM-29-205-g004.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/fbe9/8563040/f77fca344873/AIM-29-205-g001.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/fbe9/8563040/f689194fa411/AIM-29-205-g002.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/fbe9/8563040/c458efce9dba/AIM-29-205-g003.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/fbe9/8563040/9541d5dacb98/AIM-29-205-g004.jpg

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本文引用的文献

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European Federation for Medical Informatics - the Most Influential Promoter of Medical Informatics Development for the Past 45 Years.欧洲医学信息学联合会——过去45年里医学信息学发展最具影响力的推动者。
Acta Inform Med. 2021 Jun;29(2):80-93. doi: 10.5455/aim.2021.29.80-93.
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An Overview of Human Resources and Capacity in Health Care Institutions in the Federation of Bosnia and Herzegovina in the Context of Responding to the COVID 19 Pandemic.波斯尼亚和黑塞哥维那联邦医疗机构在应对新冠疫情背景下的人力资源与能力概述
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Leveraging Electronic Dental Record Data for Clinical Research in the National Dental PBRN Practices.
利用国家牙科 PBRN 实践中的电子牙科记录数据进行临床研究。
Appl Clin Inform. 2020 Mar;11(2):305-314. doi: 10.1055/s-0040-1709506. Epub 2020 Apr 29.
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Completeness of Electronic Dental Records in a Student Clinic: Retrospective Analysis.学生诊所电子牙科记录的完整性:回顾性分析
JMIR Med Inform. 2019 Mar 21;7(1):e13008. doi: 10.2196/13008.
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Clinical documentation of dental care in an era of electronic health record use.电子健康记录使用时代的牙科保健临床记录。
J Evid Based Dent Pract. 2016 Sep;16(3):154-160. doi: 10.1016/j.jebdp.2016.07.001. Epub 2016 Jul 21.
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Importance of dental records in forensic dental identification.牙科记录在法医牙科学鉴定中的重要性。
Acta Inform Med. 2015 Feb;23(1):49-52. doi: 10.5455/aim.2015.23.49-52. Epub 2015 Feb 22.
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A qualitative analysis evaluating the purposes and practices of clinical documentation.一项评估临床记录目的与实践的定性分析。
Appl Clin Inform. 2014 Feb 26;5(1):153-68. doi: 10.4338/ACI-2013-10-RA-0081. eCollection 2014.
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What's the deal with dental records for practicing dentists? Importance in general and forensic dentistry.执业牙医的牙科记录是怎么回事?在普通牙科和法医牙科中的重要性。
J Forensic Dent Sci. 2014 Jan;6(1):9-15. doi: 10.4103/0975-1475.127764.
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Information systems in dentistry.牙科信息系统。
Acta Inform Med. 2012 Mar;20(1):47-55. doi: 10.5455/aim.2012.20.47-55.
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Medical providers' dental information needs: a baseline survey.医疗服务提供者的牙科信息需求:一项基线调查。
Stud Health Technol Inform. 2011;169:387-91.