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At least 19 recordsLinked to original sources
PubMed1976

Use of a problem-oriented dental record in undergraduate dental education.

This paper describes how the concepts and methods of problem-orientation have been applied in the clinical education of dental students. It makes the point that the problem-oriented dental record is only one part of a complete system which has five interrelated components. The problem-oriented dental record is discussed in detail, and the paper includes examples of all four sections of the record. All sections of the record are interrelated, and the steps in identifying and resolving problems follow a logical sequence: (1) collect the data base, (2) write the cue list, (3) write the problem list, (4) write the initial plan, (5) write the final plan, and (6) record progress. The problem-oriented dental record is seen as a tool for patient care, audit, and education. The main advantage lies in the way information is organized and recorded. The record is highly communicative and permits everyone involved an opportunity to relate the data collected to the problem list and to the decisions made regarding how problems will be resolved. The record and the systems were borrowed from Weed and are being adapted for use in dentistry. Although still in the trial stages, this system has proven to have many more advantages than other record-keeping systems and is invaluable as a tool for education. In the future we plan to use computers to help store and retrieve data from these records. We anticipate that a dental education built on this record will have a lasting impact on the graduates' approach to patient care. This should result in a graduate who is conversant with medical colleagues and systematic in the collection of data, listing of problems, and resolution of patient problems. Finally, we believe that the problem-oriented dental record is also a good tool to help the dental graduate become more empathetic with patients and more aware of their total health needs. The record provides a mechanism for recording physical and emotional information as well as the oral status.

Dental Records↗
PubMed1996

Dental records.

Explore the source record for details and available documents.

Dental Records↗
PubMed2006

[Dental records and responsibility].

Dental records are more than a small part of the bookkeeping. In most dental practises, keeping records is the task of a dental assistant. In civil court, the dentist is in most countries liable for the mistakes of his employees. In disciplinary court however there may be doubt whether the dentist is responsible for the mistakes of his assistant. Contrary to their American colleagues, Dutch dental assistants and dental hygienists cannot be summoned before a disciplinary court. As these para-medics perform more and more dental treatment, independently or after delegation, they should be assigned there own disciplinary responsibility.

Dental Assistants↗
PubMedDate not supplied

Correlation of dental-record medical histories with outpatient medical records.

Medical history questionnaires and outpatient medical records of 115 patients were compared. All patients had a medical history of at least two years in both records. The dental records were initially reviewed, and patients' responses were compiled; when these were compared with the outpatient medical records, the overall discrepancy rate was > 86 percent. This overwhelming rate of error should make dentists aware that many routinely treated patients have medical conditions that are unknown to providers. Use of universal precautions, adequate medical-emergency training, and oral review of the dental health questionnaire are recommended.

Adult↗
PubMedDate not supplied

The problem-oriented dental record: a key to dental hygiene treatment planning and the problem-solving model for dental hygiene practice.

The problem-solving model for dental hygiene practice requires careful assessment, planning, implementation and evaluation to provide quality dental hygiene care. To facilitate this problem-solving approach, a method of recording information in an organized and highly communicative manner must be established. This paper describes the components of a problem-oriented dental record used by students at the Vancouver Community College and discusses the benefits of using this tool in clinical practice.

Dental Hygienists↗
PubMed1978

Ownership and maintenance of dental records.

The maintenance of good dental records is essential for the defense of a professional liability claim. If a dentist must give records and radiographs to a patient, insurance carrier, or succeeding practitioner, he should always give copies and maintain the originals. As a professional liability claim can often be filed long after treatment ceases, the dentist should retain his records permanently. The right of a patient to gain access to his medical or dental records has been granted by recent court decisions as well as by laws and regulations enacted in some states. The court decisions granting a patient access to his records are law in the jurisdictions in which the cases were decided. However, those decisions would present persuasive authority in a stage having no case law or statute regarding access by the patient to medical or dental records. The dentist should consult his attorney to determine the local law before allowing a patient access to his records and radiographs.

Dental Records↗
PubMed1999

Self-assessment of the forensic value of dental records.

One of the most important aspects of a person's dental record may well prove to be it's potential value should the forensic dental identification of their remains become necessary. The better the quality of the antemortem dental records, the easier and faster the identification of the remains will be. The forensic dentist must be able to select identifying features by decoding the deceased's antemortem dental records. A study was conducted on two groups of dentists who were asked to self-assess the forensic dental value of the dental records maintained in their own practices. The three most frequently recorded identifying dental features, other than caries and restorations, were the presence of diastemas, displaced or rotated teeth, and dental anomalies. Surveyed dentists imbedded identifying information into the removable prosthetic devices fabricated for their patients an average of only 64% of the time. Only 56% of the two groups combined felt that their dental chartings and written records would be extremely useful in dental identifications. It is concluded that the quality of antemortem dental records available for comparison to postmortem remains varies from inadequate to extremely useful. Practicing dentists can become valuable members of the dental identification process by developing and maintaining standards of record keeping which would be valuable in restoring their patients' identity.

Adult↗
PubMed2000

Adequacy of dental records in clinical practice: a survey of dentists.

PURPOSE: The purposes of the study were to determine Minnesota dentists' perception of the adequacy of their dental record documentation, assess the general format and contents of dental records they used, and compare the self-reported contents of dental records with guidelines established by the American Dental Association (ADA). METHOD: Using ADA's published recommendations for structure and guidelines of the dental record from 1987, a 20-item questionnaire was developed, pretested, and used to survey a random sample of 750 Minnesota dentists. Reminder postcards were sent two weeks after the initial survey mailing. A third mailing to nonrespondents, including cover letter and duplicate questionnaire, was conducted three weeks later. Of the surveys returned, 63% (N = 475) were analyzed. Data analyses, including frequencies and tests of chi-square, were conducted using Statview and SPSS. RESULTS: While 15% (N = 69) of respondents used a single-page record format, 44% (N = 209) used multiple forms filed in a specific location within the record. Of the dentists responding, 403 (85%) felt their record documentation was adequate without comparison to any specified criteria. However, statistically significant differences occurred between dentists' perception of record adequacy and the actual presence or absence of ADA criteria for all record components. Data analysis revealed that information was absent 9.4% to 87.1% of the time. CONCLUSION: A discrepancy exists between dentists' perception of dental record adequacy and the ADA recommendations for structure and guidelines. Inadequate dental record components should be targeted for improvement.

American Dental Association↗
PubMed1991

Charting accuracy in Navy dental records.

Eighty-five Navy patients and their dental records were reviewed, to determine the accuracy of the recorded initial findings in the SF603 Dental Record, and any subsequent treatment recordings. These findings were compared to those of a similar study published in 1970, and comparisons were drawn between the two reviews as to the accuracy of the charting and usefulness for forensic dental identification. A possible future concern in forensic dental identification was identified and is discussed.

Dental Records↗
PubMed2006

Dental records: a Belgium study.

The aim of this study was to deduce the quality of the average dental record kept by Belgian dentists and to evaluate its potential use for forensic dental casework. The evaluated material originated from 598 Dutch speaking and 124 French speaking Belgian dentists who completed a questionnaire and returned it by mail or through the internet. The age of the participating dentists ranged from 22 to 72 years of age. The results of the inquiry were statistically analysed taking parameters such as language, gender, age, university and ZIP code into account. In general there was a tendency for the young dentists from the age category 22 to 34 years of age, especially those living in larger cities, to perform better on several of the questions asked such as completion of the dental record, storage of x-rays, working with digital x-rays and a digital dental record.

Adult↗
PubMed1996

Legal issues of the electronic dental record: security and confidentiality.

Computer-based, electronic dental record keeping involves complex issues of patient privacy and the dental practitioner's ethical duty of confidentiality. Federal and state law is responding to the new legal issues presented by computer technology. Authenticating the electronic record in terms of ensuring its reliability and accuracy is essential in order to protect its admissibility as evidence in legal actions. Security systems must be carefully planned to limit access and provide for back-up and storage of dental records. Carefully planned security systems protect the patient from disclosure without the patient's consent and also protect the practitioner from the liability that would arise from such disclosure. Human errors account for the majority of data security problems. Personnel security is assured through pre-employment screening, employment contracts, policies, and staff education. Contracts for health information systems should include provisions for indemnification and ensure the confidentiality of the system by the vendor.

Computer User Training↗