title: Presence of periodontal data in patient records of general practitioners.
abstract: It has been reported that little diagnostic information concerning periodontal conditions is entered in patient records of general practitioners, but actual rates for such chart entries are unknown. Records of regular patients, seen at least annually, were randomly selected from the offices of 36 general practitioners in two North Carolina counties. In each office 80 records were selected for audit. After adjustment, the final sample consisted of 2488 audited records. Entries noting the presence or absence of 14 diagnostic conditions were identified for the five previous years and for the patient's most recent examination. The presence of a periodontal diagnosis or periodontal treatment plan was noted. The number of radiographic sets exposed in the previous five years and the age of the most recent set were determined for complete series/panoramic films and for bitewings. Across practices, the most frequent notations (20.5% within the past five years) concerned the presence of probing depths and calculus. Gingival bleeding (13%) and plaque (12%) were noted less frequently. A periodontal diagnosis was recorded in only 16.3% of the records. Annualized rates for radiographic sets were 0.09 for complete series/panoramic films and 0.50 for bitewings. These data suggest that, except for radiographs, the majority of patient records do not contain sufficient diagnostic information to describe patients' periodontal health.
authors.affiliation: School of Dentistry, University of North Carolina, Chapel Hill.
authors.forename: W T
authors.initials: WT
authors.lastname: McFall
authors.forename: J D
authors.initials: JD
authors.lastname: Bader
authors.forename: R G
authors.initials: RG
authors.lastname: Rozier
authors.forename: D
authors.initials: D
authors.lastname: Ramsey
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003792:Dental Records; D005260:Female; D005792:General Practice, Dental; D006801:Humans; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D010510:Periodontal Diseases / Q000175:diagnosis* / Q000473:pathology