Evaluation Study of Outpatient Medical Record Writing Items by Dentists in Sichuan Province
Objective To understand the importance evaluation and differences between the national prescribed writing items and other supplementary writing items for outpatient medical records by dentists in Sichuan Province,and to provide reference for exploring the establishment of a unified outpatient medical record for stomatology.Methods In December 2022,a questionnaire survey was conducted among 611 dentists from 359 dental medical institutions in Sichuan province.The importance of outpatient medical record adopts the Likert 5-level scoring method.Analysis of variance was used to compare the differences in the evaluation of supplementary writing items by dentists with different characteristics.Results The average score of dentists on both the national prescribed writing items and supplementary writing items(except for height and weight)of oral outpatient medical records was≥4 scores.According to the national regulations,the highest scoring items in the writing items were the main complaint and diagnosis,while the highest scoring items in the supplementary writing items were the history of infectious diseases and the history of allergies to dental materials.There were statistically significant differences in the evaluation of supplementary writing items among dentists with different educational backgrounds,professional titles,positions,and from different medical institutions(P＜0.05).Conclusion It is important for dentists in Sichuan province to evaluate both the national prescribed writing items and supplementary writing items for outpatient medical records.Based on the relevant national laws and regulations,and referring to the suggestions and actual work needs of employees from different professional titles,positions,and dental medical institutions,writing items that are conducive to clinical diagnosis and treatment,such as"dietary habits,oral health care habits,regular oral examinations,patients'attitude towards oral anesthesia treatment,infectious disease history,and dental material allergy history",are included in the medical record writing,which is conducive to establishing a more comprehensive dental outpatient medical records suitable for the dental profession.
DentistOutpatient medical recordImportance evaluation
万方数据
维普
