Quality evaluation of patient records in Swedish dental care
Rasmusson, L.; René, N.; Dahlbom, U.; Borrman, H.
Swedish Dental Journal 18(6): 233-241
1994
ISSN/ISBN: 0347-9994 PMID: 7725237 Document Number: 423679
The purposes of this study were to evaluate systematically five patient records each from randomly selected dentists in different regions of Sweden in 1992, and to see whether the good knowledge of some record-keeping rules, noted earlier, was reflected in practical observance of the rules as a whole. Observance was generally poor: in nearly 40% of the variables investigated, the documentation did not follow the rules. Patient history, status, diagnosis, therapy plans and other important information were often missing among the records from the general practitioners. The specialists' records, however, were in general very accurate. As a whole, Swedish dental patient records constitute poor antemortem material for forensic odontology. The dentist's age is related to the quality of the records. The standard of the patient records must be improved.