Cardiology and Angiology: An International Journal

Integrated health documentation captures, imports and exports relevant extract of patient’s longitudinal health information record. Especially documenting patients’ chronic disease data in dental documentation system is crucial.

Aim: Analyze chronic patients’ health information integrity in dental documentation during orodontal procedures and correlates affecting this relationship.

Methods: Dental records of chronic disease patients in Qena University Hospital (QUH) between 2012 and 2015 were compared with paired medical records to achieve study aim. Medical information studied included an array of health condition inquiries.

Results: The patients’ age averaged 55±15y, (range 21-84=63y); 58.2% (n=189) were male. Most dental examinations were attended by resident/registrar dentists (72.1%). A total of 1644 discordant data representation between dental and medical pair of records has been identified. More than half (53.7%; n=995) of disease items as in medical records were missing, and 0.8% (n=35) of disease items not among the patients’ history were “falsely” endorsed in dental records [χ²(df=1)= 2385.5   p<0.0001]. Patients’ age was associated with proneness to neglecting health data while submitting to orodontal care [Fisher’s exact = 15.2, p<0.0001]. Male dentists tended to report more discordant data incidents (97% vs. 90%) [χ²(1)= 7.3, p=0.007]. Less professional staff, and less experienced, tend to report discordantly more frequently than senior peers (96.6% vs. 84.2%, respectively) [Fisher’s exact 8.3, p=0.028].

Conclusions: This study reveals the presence of miscommunication of health information of chronic disease patients between dental and medical records. Both patients’ criteria and the practitioners’ data management attitude may be incriminated. A standardized documentation system saves chronic disease patients the health and economic consequences of discordant data representation in records.