A comparison of computer- and hand-generated clinical dental notes with statutory regulations in record keeping
Version of Record online: 22 MAR 2011
© 2011 John Wiley & Sons A/S
European Journal of Dental Education
Volume 16, Issue 1, pages e117–e121, February 2012
How to Cite
McAndrew, R., Ban, J. and Playle, R. (2012), A comparison of computer- and hand-generated clinical dental notes with statutory regulations in record keeping. European Journal of Dental Education, 16: e117–e121. doi: 10.1111/j.1600-0579.2011.00684.x
- Issue online: 18 JAN 2012
- Version of Record online: 22 MAR 2011
- Accepted: 8 February 2011
- clinical records;
- record keeping;
Introduction: Dental patient records should be of high quality, contain information to allow for good continuity of care and clinical defence (should the need ever arise) and, ideally, facilitate clinical audit. Handwritten dental records have been assessed for their compliance to statutory regulations, but the same cannot be levelled at computer-generated notes. This study aimed to compare and analyse the compliance of both methods of data recording with statutory regulations.
Method: Fifty consecutive sets of handwritten notes and 50 sets of computer-generated notes were audited for compliance with a number of legal requirements and desirable characteristics for dental records and the results compared. The standard set for compliance with all characteristics was 100%.
Results: The computer-generated notes satisfied the set standard for 8 of the 11 legal requirements and three of six desirable characteristics. The handwritten notes satisfied the set standard for 1 of 11 legal requirements and none of the desirable characteristics. A statistical difference (using a 95% confidence interval) between the two methods was observed in 5 of 11 legal characteristics and three of six desirable characteristics, all of which were in favour of computer-generated notes.
Conclusions: Within the limitations of this study, computer-generated notes achieved a much higher compliance rate with the set parameters, making defence in cases of litigation, continuity of care and clinical audit easier and more efficient.