A Qualitative Investigation of the Content of Dental Paper-based and Computer-based Patient Record Formats

摘要

Objective: Approximately 25% of all general dentists practicing in the United States use a computer in the dental operatory. Only 1.8% maintain completely electronic records. Anecdotal evidence suggests that dental computer-based patient records (CPR) do not represent clinical information with the same degree of completeness and fidelity as paper records. The objective of this study was to develop a basic content model for clinical information in paper-based records and examine its degree of coverage by CPRs. Design: We compiled a baseline dental record (BDR) from a purposive sample of 10 paper record formats (two from dental schools and four each from dental practices and commercial sources). We extracted all clinical data fields, removed duplicates, and organized the resulting collection in categories/subcategories. We then mapped the fields in four market-leading dental CPRs to the BDR. Measurements: We calculated frequency counts of BDR categories and data fields for all paper-based and computer-based record formats, and cross-mapped information coverage at both the category and the data field level. Results: The BDR had 20 categories and 363 data fields. On average, paper records and CPRs contained 14 categories, and 210 and 174 fields, respectively. Only 72, or 20%, of the BDR fields occurred in five or more paper records. Categories related to diagnosis were missing from most paper-based and computer-based record formats. The CPRs rarely used the category names and groupings of data fields common in paper formats. Conclusion: Existing paper records exhibit limited agreement on what information dental records should contain. The CPRs only cover this information partially, and may thus impede the adoption of electronic patient records. © 2007 J Am Med Inform Assoc.