Please use this identifier to cite or link to this item:
https://hdl.handle.net/2440/95729
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Type: | Journal article |
Title: | Australian oral health case notes: assessment of forensic relevance and adherence to recording guidelines |
Author: | Stow, L. James, H. Richards, L. |
Citation: | Australian Dental Journal, 2016; 61(2):236-243 |
Publisher: | Wiley |
Issue Date: | 2016 |
ISSN: | 0045-0421 1834-7819 |
Statement of Responsibility: | Lauren Stow, Helen James and Lindsay Richards |
Abstract: | BACKGROUND: Dental case notes record clinical diagnoses and treatments, as well as providing continuity of patient care. They are also used for dento-legal litigation and forensic purposes. Maintaining accurate and comprehensive dental patient records is a dental worker's ethical and legal obligation. METHODS: Australian-registered specialist Forensic Odontologists were surveyed to determine the relevance of recorded case note items for dental identification. A dental case notes sample was assessed for adherence with Odontologist-nominated forensic value and compiled professional record keeping guidelines of forensic relevance. Frequency of item recording, confidence interval, examiner agreement and statistical significance were determined. RESULTS: Broad agreement existed between Forensic Odontologists as to which recorded dental items have most forensic relevance. Inclusion frequency of these items in sampled case notes varied widely (eg. single area radiographic view present in 75%, CI=65.65-82.50; completed odontogram in 56%, CI=46.23-65.33). Recording of information specified by professional record keeping guidelines also varied, although overall inclusion was higher than for forensically-desired items (eg. patient's full name in 99%, CI=94.01->99.99; named treating practitioner in 23%, CI=15.78-32.31). CONCLUSION: Many sampled dental case notes lacked details identified as being valuable by forensic specialists and as specified by professional record keeping guidelines. |
Keywords: | Adherence case notes dental forensic guidelines |
Rights: | © 2016 Australian Dental Association |
DOI: | 10.1111/adj.12350 |
Published version: | http://dx.doi.org/10.1111/adj.12350 |
Appears in Collections: | Aurora harvest 3 Dentistry publications |
Files in This Item:
File | Description | Size | Format | |
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hdl_95729.pdf | Accepted version | 378.43 kB | Adobe PDF | View/Open |
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