Analyzing Medication Documentation in Electronic Health Records: Dental Students' Self‐Reported Behaviors and Charting Practices

Abstract

The aim of this two‐part study was to assess third‐ and fourth‐year dental students' perceptions, self‐reported behaviors, and actual charting practices regarding medication documentation in axiUm, the electronic health record (EHR) system. In part one of the study, in fall 2015, all 125 third‐ and 85 fourth‐year dental students at one U.S. dental school were invited to complete a ten‐item anonymous survey on medication history‐taking. In part two of the study, the EHRs of 519 recent dental school patients were randomly chosen via axiUm query based on age >21 years and the presence of at least one documented medication. Documentation completeness was assessed per EHR and each medication based on proper medication name, classification, dose/frequency, indication, potential oral effects, and correct medication spelling. Consistency was evaluated by identifying the presence/absence of a medical reason for each medication. The survey response rate was 90.6% (N=187). In total, 64.5% of responding students reported that taking a complete medication history is important and useful in enhancing pharmacology knowledge; 90.4% perceived it helped improve their understanding of patients' medical conditions. The fourth‐year students were more likely than the third‐year students to value the latter (p=0.0236). Overall, 48.6% reported reviewing patient medications with clinic faculty 76‐100% of the time. The respondents' most frequently cited perceived barriers to medication documentation were patients' not knowing their medications (68.5%) and, to a much lesser degree, axiUm limitations (14%). Proper medication name was most often recorded (93.6%), and potential oral effects were recorded the least (3.0%). Medication/medical condition consistency was 70.6%. In this study, most of the students perceived patient medication documentation as important; however, many did not appreciate the importance of all elements of a complete medication history, and complete medication documentation was low.

Retrospective Study of the Reasons and Time Involved for Dental Providers' Medical Consults

“…Additionally, despite using a small sample size, an in-depth exploratory analysis was conducted on each medical consult utilizing a minimum of 17 components. Nevertheless, the results regarding the reasons for seeking medical consults are consistent with other studies and related reports ( 15 – 17 , 21 ). Like other studies conducted in a single setting, the findings from this study have limited generalizability outside of the IUSD or the academic dental environment.…”

“…The patient's inability to provide enough medical information to continue with care could have prompted dental providers to seek medical consults. A recent survey of dental providers ( 21 ) in our institution reported patients' limited knowledge of their medications, as a significant barrier to obtaining complete medication history. Other studies also suggest that patients, especially older patients with multiple chronic conditions, have difficulty recalling their medical and medication histories ( 22 , 23 ), thus negatively affecting dental providers' patient care.…”

Leveraging Electronic Dental Record Data for Clinical Research in the National Dental PBRN Practices

“…16 A few studies have evaluated the completeness and correctness of EDR data in academic institutions to identify gaps and improve dental students' training for patient care documentation. [20][21][22] These studies indicate the need to establish a systematic process to evaluate the data quality of EDR-derived datasets and to promote fidelity and reproducibility of secondary data analysis.…”

How Do Dental Clinicians Obtain Up-To-Date Patient Medical Histories? Modeling Strengths, Drawbacks, and Proposals for Improvements

“…Furthermore, patient-reported medical histories place a significant burden on patients who may have limited medical knowledge, especially older patients with multiple chronic conditions. Studies have reported patient's difficulty recalling their medical and medication histories, which may negatively affect the dental care process ( 8 – 10 ). Therefore, to obtain complete information, the DCs will consult the patients' physicians through medical consults.…”

“…Therefore, it is critical to establish uninterrupted interaction between dental and medical settings to overcome inconsistent documentation and communication problems, and to improve access to up-to-date patient medical history. This interaction could help avoid the potential for fatal accidents and maintain patient safety during dental care ( 1 , 5 , 6 , 8 , 12 ).…”