ArticleJMIR medical informatics2019
Completeness of Electronic Dental Records in a Student Clinic: Retrospective Analysis.
Article in JMIR medical informatics, 2019. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 5 papers.
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Who cites it
5 citing papers in PubMed, 16 citations in OpenAlex.
- Application of digital simulations for clinical assessment and documentation of temporomandibular disorders: a retrospective study.Oral surgery, oral medicine, oral pathology and oral radiology · 2026Article
- Multimodal Large Language Models for Dental Chart Image Interpretation: Cross-Sectional Benchmarking Study With Students and Clinicians.JMIR medical education · 2026Article
- Dental Recordkeeping: Practice in Federation of Bosnia and Herzegovina.Acta informatica medica : AIM : journal of the Society for Medical Informatics of Bosnia & Herzegovina : casopis Drustva za medicinsku informatiku BiH · 2021Article
- Using big data to promote precision oral health in the context of a learning healthcare system.Journal of public health dentistry · 2020Review
- Leveraging Electronic Dental Record Data for Clinical Research in the National Dental PBRN Practices.Applied clinical informatics · 2020Article
Corrections and comments
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Authors and funding
3 authors at 2 institutions in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundA 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.
objectiveThe goal of this study was to assess the completeness of electronic patient records in a student clinic.
methodsCompleteness 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.
resultsOverall, 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).
conclusionsThere 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.
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