Adequacy of dental records in clinical practice: a survey of dentists.

PURPOSE: The purposes of the study were to determine Minnesota dentists' perception of the adequacy of their dental record documentation, assess the general format and contents of dental records they used, and compare the self-reported contents of dental records with guidelines established by the American Dental Association (ADA). METHOD: Using ADA's published recommendations for structure and guidelines of the dental record from 1987, a 20-item questionnaire was developed, pretested, and used to survey a random sample of 750 Minnesota dentists. Reminder postcards were sent two weeks after the initial survey mailing. A third mailing to nonrespondents, including cover letter and duplicate questionnaire, was conducted three weeks later. Of the surveys returned, 63% (N = 475) were analyzed. Data analyses, including frequencies and tests of chi-square, were conducted using Statview and SPSS. RESULTS: While 15% (N = 69) of respondents used a single-page record format, 44% (N = 209) used multiple forms filed in a specific location within the record. Of the dentists responding, 403 (85%) felt their record documentation was adequate without comparison to any specified criteria. However, statistically significant differences occurred between dentists' perception of record adequacy and the actual presence or absence of ADA criteria for all record components. Data analysis revealed that information was absent 9.4% to 87.1% of the time. CONCLUSION: A discrepancy exists between dentists' perception of dental record adequacy and the ADA recommendations for structure and guidelines. Inadequate dental record components should be targeted for improvement.