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Analyzing Medication Documentation in Electronic Health Records: Dental Students' Self‐Reported Behaviors and Charting Practices
Author(s) -
Burcham Wesley K.,
Romito Laura M.,
Moser Elizabeth A.,
Gitter Bruce D.
Publication year - 2019
Publication title -
journal of dental education
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.53
H-Index - 68
eISSN - 1930-7837
pISSN - 0022-0337
DOI - 10.21815/jde.019.070
Subject(s) - documentation , medicine , family medicine , medical record , consistency (knowledge bases) , geometry , mathematics , computer science , radiology , programming language
The aim of this two‐part study was to assess third‐ and fourth‐year dental students' perceptions, self‐reported behaviors, and actual charting practices regarding medication documentation in axiUm, the electronic health record (EHR) system. In part one of the study, in fall 2015, all 125 third‐ and 85 fourth‐year dental students at one U.S. dental school were invited to complete a ten‐item anonymous survey on medication history‐taking. In part two of the study, the EHRs of 519 recent dental school patients were randomly chosen via axiUm query based on age >21 years and the presence of at least one documented medication. Documentation completeness was assessed per EHR and each medication based on proper medication name, classification, dose/frequency, indication, potential oral effects, and correct medication spelling. Consistency was evaluated by identifying the presence/absence of a medical reason for each medication. The survey response rate was 90.6% (N=187). In total, 64.5% of responding students reported that taking a complete medication history is important and useful in enhancing pharmacology knowledge; 90.4% perceived it helped improve their understanding of patients' medical conditions. The fourth‐year students were more likely than the third‐year students to value the latter (p=0.0236). Overall, 48.6% reported reviewing patient medications with clinic faculty 76‐100% of the time. The respondents' most frequently cited perceived barriers to medication documentation were patients' not knowing their medications (68.5%) and, to a much lesser degree, axiUm limitations (14%). Proper medication name was most often recorded (93.6%), and potential oral effects were recorded the least (3.0%). Medication/medical condition consistency was 70.6%. In this study, most of the students perceived patient medication documentation as important; however, many did not appreciate the importance of all elements of a complete medication history, and complete medication documentation was low.