A case for diagnoses.
It is common practice to record treatment rendered, but not the diagnostic basis for these treatment decisions. This practice appears to undervalue diagnosis, as well as hamper feedback to practitioners and the profession about the effectiveness of treatments relative to specific diagnoses. It also leaves dentists open to liability for litigation and impedes research. A case is made that dentistry should follow medicine in exploring the use of standardized computer-codable diagnoses as part of record keeping. A two-step process is suggested to promote initial acceptance.
Bader
J D
JD
School of Dentistry, University of North Carolina, USA.
Shugars
D A
DA
D003657:Decision Making; D003729:Dental Care / Q000331:legislation & jurisprudence / Q000458:organization & administration; D003792:Dental Records / Q000331:legislation & jurisprudence; D003945:Diagnosis, Oral / Q000331:legislation & jurisprudence / Q000458:organization & administration*; D005246:Feedback; D005568:Forms and Records Control; D006801:Humans; D016365:Liability, Legal; D016347:Medical Records Systems, Computerized; D010347:Patient Care Planning; D011787:Quality of Health Care; D012106:Research; D012308:Risk Management; D014600:Utilization Review