Challenges in Maintaining Electronic Dental Records Electronic dental records come with many advantages and challenges in maintaining them. Medical transcription companies can support with documentation.
Accurate dental records are crucial for dentists to provide good quality patient care and follow-up as well as for legal reasons. Electronic dental records (EDR) or electronic oral health records combine processes and data structures used by dentists for purposes of documenting or conveying clinical facts, diagnoses, treatment plans, and services provided (American Dental Association (ADA)). Medical transcription companies support dental offices in documenting the history of the illness, physical examination, diagnosis, treatment, and management of a patient in the EDR system. Efficient EDRs capture patient data in a structured format system and come with advanced features such as treatment planning, specific protocols, electronic prescribing, clinical workflow, clinical alerts, and other integrated features.
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EDRs drive practice efficiency. They offer various documentation options, make digital images easily accessible, provide instant access to a patient’s dental history, improve collaboration between medical and dental care practitioners, and make clinical data available for research purposes. EDR challenges While EDRs offer manu benefits, there are certain challenges involved in maintaining EDRs:
The EDR needs to be updated with large amount of information including dentists’ notes, results of special investigations, referral letters, laboratory prescriptions, patient identification information, comprehensive medical history and more.
It is important in dentistry to enter information in the record contemporaneously 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.
Frequent use of copy-and-paste functions and templates is a major concern. While copyand-paste functions are useful for certain aspects, a cloned entry from a previous record can pose significant dento-legal risks.
New dental professionals may be familiar with the common terms used while providing patient care and maintaining dental records, but they may not be knowledgeable about new terms. Usage of accurate clinical terms is important for choosing the correct CDT Code for patient record-keeping and claim preparation. Medical transcription service providers should also be aware of such important terms and must be 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. Healthcare professionals can provide comprehensive care by integrating EDRs with medical records. Professional dentistry transcription services can resolve many of the challenges associated with maintaining EDRs.
www.medicaltranscriptionservicecompany.com
918-221-7801