Maintaining Accurate Electronic Dental Record (EDRs) – Critical Considerations

Electronic Dental Record

The electronic dental record (EDR) also known as the electronic oral health record is an electronic health record (EHR). The American Dental Association (ADA) defines the EDR as “a combination of processes and data structures, used by dentists, for purposes of documenting or conveying clinical facts, diagnoses, treatment plans, and services provided”. Dental professionals need to maintain and produce accurate dental records to support good quality patient care and follow-up as well as for legal reasons. Many dental offices rely on medical transcription companies to document of the history of the illness, physical examination, diagnosis, treatment, and management of a patient in the EDR system. Such support enables efficient dental record keeping, which has become increasingly important due to the following reasons:

  • The prevalence of severe periodontal diseases in about 25% of people age 65-74 years old
  • Increased awareness about the importance of oral health, especially among the older population

Benefits of EDRs

  • Drives practice efficiency
  • Digital images can be easily stored and accessed
  • Provides instant access to a patient’s dental history and any pre-existing medical conditions, facilitating thorough and timely assessments
  • Can improve collaboration between medical and dental care practitioners and improve overall patient care
  • Offers various documentation options
  • Provides ease of storage and access to digital imaging
  • Can be integrated with other digital technologies and support for administrative tasks
  • Makes clinical data available for research purposes
  • can provide clinical support such as risk assessment tools and support decision-making.

Challenges of Maintaining EDRs

  • Large Amount of Information: The patient record typically comprises different elements, such as dentists’ notes, study models, radiographs, results of special investigations, referral letters, consultants’ reports, clinical photographs drug prescriptions, laboratory prescriptions, patient identification information, and a comprehensive medical history. All of this important information has to be entered accurately.
  • Records need to be Contemporaneous: In the context of dental records, the word ‘contemporaneous’ implies existing at or occurring in the same period of time, explains an article in Nature. In the dental office setting, this might mean, at the time the patient is present or immediately after, and before the next ‘period of time’ or appointment commences. Entering information in the record contemporaneously is crucial in dentistry to ensure that all important details of the treatment rendered are recorded. Time delays may result in incomplete and/or inaccurate entries as the clinician may not remember the details.
  • Copy-and-Paste Entries: The frequent and injudicious use of copy-and-paste functions, macros, templates and other tools by dentists is reported to be a major concern. While copy-and-paste and using standardized text are useful for certain aspects, a cloned entry from a previous record can pose significant dento-legal risks.
  • Knowledge about New Terms: Dentists and their staff use many terms in the course of providing patient care, maintaining dental records and preparing insurance claims. However, over time, new terms are introduced and old ones are revised. The ADA points out that while new dental professionals may be familiar with common terms, they may not be knowledgeable about new terms. Knowing these clinical terms is crucial for choosing the correct CDT Code for patient record-keeping and claim preparation. It is also important for medical transcription service providers to be aware about these terms. In fact, experienced medical transcriptionists who provide dentistry transcription services stay up to date on the glossary of dental and administrative terms available on the ADA’s website.

With its many benefits, EDR adoption and integration into the dental office is rising. Efficient electronic dental record systems capture patient data in a discrete or structured format system and come with advanced features such as treatment planning, specific protocols, electronic prescribing, clinical workflow, clinical alerts, and other integrated features. EDR integration with medical records allows healthcare professionals to provide comprehensive care. Outsourcing transcription to a company that specializes in dentistry transcription services can resolve many of the challenges associated with maintaining EDRs.