Analysis of clinical records of dental patients attending Jordan University Hospital: Documentation of drug prescriptions and local anesthetic injections.
Analysis of clinical records of dental patients attending Jordan University Hospital: Documentation of drug prescriptions and local anesthetic injections.
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DOI：
10.2147/tcrm.s3727
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发表时间：
2008-10
影响因子：
2.8
通讯作者：
Abu-Hammad O
中科院分区：
文献类型：
--
作者：
Dar-Odeh N;Ryalat S;Shayyab M;Abu-Hammad O
本研究的目的是分析在约旦大学医院（约旦的一家教学医院）牙科部门就诊的牙科患者的临床记录。分析旨在确定牙科专家是否正确记录了给患者的药物处方和局部麻醉注射。约旦大学医院牙科部在2007年4月3日至4月26日期间的牙科记录以及该期间开具的处方均经过审查。在此期间，共审查了 1000 条记录，共开具了 53 份处方。三十条记录通过说明处方药物的类别来记录处方。只有 13 条记录注明了处方药物的通用名或商品名。其中，5 条记录包含处方的完整要素。至于局部麻醉注射，有 22 条记录中发现了“使用局麻药”一词，而仅记录了 13 条记录中记录了所用局部麻醉药的名称和数量。只有 5 条记录记录了局部麻醉注射的全部内容。接受调查的牙科专家小组对药物处方和局部麻醉注射的基本数据记录很少。建议医院和牙科部门的管理部门为牙科医生实施明确而严格的指导方针，特别是执行所需的文件程序。
The aim of this study was to analyze clinical records of dental patients attending the Dental Department at the University of Jordan Hospital: a teaching hospital in Jordan. Analysis aimed at determining whether dental specialists properly documented the drug prescriptions and local anesthetic injections given to their patients. Dental records of the Dental Department at the Jordan University Hospital were reviewed during the period from April 3rd until April 26th 2007 along with the issued prescriptions during that period. A total of 1000 records were reviewed with a total of 53 prescriptions issued during that period. Thirty records documented the prescription by stating the category of the prescribed drug. Only 13 records stated the generic or the trade names of the prescribed drugs. Of these, 5 records contained the full elements of a prescription. As for local anesthetic injections, the term “LA used” was found in 22 records while the names and quantities of the local anesthetics used were documented in only 13 records. Only 5 records documented the full elements of a local anesthetic injection. The essential data of drug prescriptions and local anesthetic injections were poorly documented by the investigated group of dental specialists. It is recommended that the administration of the hospital and the dental department implement clear and firm guidelines for dental practitioners in particular to do the required documentation procedure.