title: Development and initial validation of a content taxonomy for patient records in general dentistry.
abstract: OBJECTIVE
  Develop and validate an initial content taxonomy for patient records in general dentistry.
  
  
  METHODS
  Phase 1 - obtain 95 de-identified patient records from 11 general dentists in the United States. Phase 2 - extract individual data fields (information items), both explicit (labeled) and implicit (unlabeled), from records, and organize into categories mirroring original field context. Phase 3 - refine raw list of information items by eliminating duplicates/redundancies and focusing on general dentistry. Phase 4 - validate all items regarding inclusion and importance using a two-round Delphi study with a panel of 22 general dentists active in clinical practice, education, and research.
  
  
  RESULTS
  Analysis of 76 patient records from 9 dentists, combined with previous work, yielded a raw list of 1509 information items. Refinement reduced this list to 1107 items, subsequently rated by the Delphi panel. The final model contained 870 items, with 761 (88%) rated as mandatory. In Round 1, 95% (825) of the final items were accepted, in Round 2 the remaining 5% (45). Only 45 items on the initial list were rejected and 192 (or 17%) remained equivocal.
  
  
  CONCLUSIONS
  Grounded in the reality of clinical practice, our proposed content taxonomy represents a significant advance over existing guidelines and standards by providing a granular and comprehensive information representation for general dental patient records. It offers a significant foundational asset for implementing an interoperable health information technology infrastructure for general dentistry.
authors.affiliation: Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield, WI, USA. Electronic address: acharya.amit@mcrf.mfldclin.edu.
authors.forename: Amit
authors.initials: A
authors.lastname: Acharya
authors.forename: Pedro
authors.initials: P
authors.lastname: Hernandez
authors.forename: Thankam
authors.initials: T
authors.lastname: Thyvalikakath
authors.forename: Harold
authors.initials: H
authors.lastname: Ye
authors.forename: Mei
authors.initials: M
authors.lastname: Song
authors.forename: Titus
authors.initials: T
authors.lastname: Schleyer
mesh_terms: D002965:Classification; D003697:Delphi Technique; D003792:Dental Records; D006801:Humans; D008490:Medical Informatics; D016347:Medical Records Systems, Computerized; D011215:Practice Management, Dental; D016730:Program Development; D011795:Surveys and Questionnaires
keywords: Delphi technique; Dental informatics; Dental records/standards; Dentists’ practice patterns/standards; Information management; Information storage and retrieval