J Interdiscip Dentistry
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Table of Contents
INVITED REVIEW
Year : 2014  |  Volume : 4  |  Issue : 2  |  Page : 62-65

Patient record and communication in interdisciplinary dentistry


Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal University, Mangalore, Bengaluru, Karnataka, India

Date of Web Publication15-Oct-2014

Correspondence Address:
Neeta Shetty
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal University, Mangalore, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.142934

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   Abstract 

Well-maintained records and good communication are essentials tools in modern dentistry. The right components of a dental record and appropriate communication skills by far provide a step forward in quality dental treatment. This article discusses the importance of both, good records and communication skills, in interdisciplinary dentistry and provides an overview of the components involved.
Clinical Relevance to Interdisciplinary Dentistry

  • Clinical relevance to interdisciplinary dentistry- The overall management of a dental patient requires a holistic and interdisciplinary approach, involving areas such as management of records and establishing a chain of communication. The various factors and components that support the same are discussed.

Keywords: Communication, interdisciplinary dentistry, patient record, tools


How to cite this article:
Sawhney S, Kundabala M, Shetty N, Thomas M. Patient record and communication in interdisciplinary dentistry. J Interdiscip Dentistry 2014;4:62-5

How to cite this URL:
Sawhney S, Kundabala M, Shetty N, Thomas M. Patient record and communication in interdisciplinary dentistry. J Interdiscip Dentistry [serial online] 2014 [cited 2019 Jun 20];4:62-5. Available from: http://www.jidonline.com/text.asp?2014/4/2/62/142934


   Introduction Top


We dentists don't just deliver dentistry, we are here to share our values and integrity and change lives. How well do we understand the term "communication?" George Bernard Shaw had once said that, the single biggest problem in communication is the illusion, that it has taken place. Very well said indeed, as today, the most important tool in modern dentistry lies in the ability to be able to express, share, teach and learn. How many of us do consider ourselves able to do so?

Interdisciplinary dentistry, has for years now, been the protocol for quality treatment and believe it or not, quality is never an accident but a wise choice of many alternatives. The interdisciplinary approach to patient care is the most valuable and always puts our patient's best interest first. That means scoring as many touchdowns as possible for our patients! Also, interdisciplinary dentistry should be given priority as early as possible because of the prime importance of diagnosis.

Like most successful sports teams, their ability to communicate with their teammates is what separates great teams from average ones. We are no different. Communication is basically defined as the imparting or exchanging of information by speaking, writing, or using some other medium. Our ability to communicate to patients, lab technicians and specialists of other departments is what separates quality treatment from average ones. The most rewarding and enjoyable cases are those which are treated with a multidisciplinary approach.

The approach to such a holistic dental treatment utilizes numerous components, an integral part of which are "patient records." For many, dental records may just be detailed documents of patient information. Definitely, they are detailed patient information documents, but more importantly, they should occupy greater significance in our day to day practice. There is now an increasing awareness among the general public of legal issues surrounding healthcare, and along with the worrying rise in malpractice cases, a thorough knowledge and better understanding of dental record issues is essential for any practitioner. The ability of clinical practitioners to produce and maintain accurate dental records is essential for good quality patient care as well as it being a legal obligation. [1]

The information in any dental record should primarily be clinical in nature. The record includes the patient's registration form comprising basic personal information. The dental team must be meticulous and thorough in the dental record keeping tasks. All information should be clearly written, and any person responsible for entering new information should sign and date the entry. The information should not have ambiguity issues or contain too many abbreviations. In practices with more than one dental practitioner, the identity of the practitioner rendering the treatment should be clearly mentioned in the record. All entries in the patient record should be dated, initialed, and handwritten in ink and/or computer printed. Handwritten entries should be legible. [2]

The record may consist of several different elements, which include written notes, radiographs, study models, referral letters, consultants' reports, clinical photographs, results of special investigations, drug prescriptions, laboratory prescriptions, patient identification information, and a comprehensive medical history. Obviously, this is a large amount of information, and it is essential that a practitioner maintains this in an easily accessible manner.

Life is as simple as we make it." Today's digital era provides us with the freedom of a number of software systems that make maintenance of records easy and feasible. Moreover advanced technology in the field of dentistry with the use of equipment such as Radiovisuography and cone-beam computed tomography make communication of information all the more simplified. Not only, is there no hassle, but we also save a lot of time. The diagnosis made by one department can be effortlessly correlated with the treatment plan of another and vice versa.

Electronic, oral health records [3] [Table 1] have evolved in the past 35 years and are sometimes also referred to as Dental Informatics." [4] A relationship exists between the various components including bibliographic referencing, data analysis, online instructions, image processing, directed reasoning for clinical decision support, direct machining of dental materials, knowledge representation of common reference material.
Table 1: Basic segments in an electronic oral health record

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Here is where the difference may present. The communication of these records in an interdisciplinary arena will provide scope for a nonhesitant approach. An approach that will instill confidence not only to the dentists' concerned but also to the patients. Patients who have confident doctors are the happiest. Needless to say, merrier the patient, merrier the dentist. "Thrive to achieve the optimum!"

Another very important aspect of communication is the "patient-dentist-technician communication" [5] [Figure 1]. A patient looks up to the dentist to restore his or her teeth to ideal health, function and esthetics. Here a dental team is created. The team of dentists and the technician. In order to achieve all expectations, it is important that the team works together and establish optimal communication with the patient. To give an example, let's assume, a restorative dentist made an impression, sent it to a dental laboratory, received the restoration and cemented it in place. But, for what-ever reason, the end result is not satisfactory. The dentist may have tried a number of different laboratories and experienced similar results. So now, the question lies, where is the problem? The preparation guidelines met the material specifications and hence that was not a problem. The directions on the instruction slips were followed, so that was also not a problem. Aha! So then, probably the dental technician was not involved in the initial steps of treatment planning, and this lack of communication may have been partially to blame. Establishing optimal effective communication and teamwork with the dental laboratory technician helps to build confidence for all cases and helps ensure consistent and successful results.
Figure 1: Patient-dentist-technician communication

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Communication among the dental team is essential and must also include the patient. Often, the patient will explain to the dentist, what he or she is expecting, this will be communicated to the lab technician by the dentist. However, most patients will have lesser understanding regarding the advancements in today's procedures and may also not understand all of the possibilities. Thus, if there is an informative communication, the patient will gain confidence in the dental team and the proposed procedure. Patients will want to know the details of the procedures being performed in a manner that they will best understand.

Some patients may not be inclined to buy immediately into a comprehensive treatment plan. The may need time to consider the extent of the treatment they are willing to pursue. By presenting a complete and understandable proposal of what is achievable, it is more likely that the patient will accept the entire proposed treatment plan. This is what is important! Once the patient is fully educated about his or her treatment, the patient has the right to make an informed decision. More so, it is this communication that retains the confidence for the patient and dentist throughout the treatment procedure.

In terms of specificity, the three specialties of periodontics, restorative and prosthodontics, share a very close bond, or union, we may call it. "Full mouth rehabilitation," is a term used very commonly, and many a times inappropriately. Taking this as an example, the basic concept behind communication among the three specialties can be understood.

Assuming, a patient reports with the three basic problems pertaining to these three specialties, poor periodontal health, decayed teeth, and few missing teeth. Yes, sounds easy? Alright, so how do we go about from here? Do we manage the periodontal health first, or should we replace the missing teeth first? Oh yes! Switch on the think tanks! Well, there is no single answer. Different patients have different needs to be catered to. A priority hierarchy should be formed. The most severe condition should be supported with immediate attention with the remaining needs followed. [Figure 2] shows the various modes of interdisciplinary communication. The initial steps may require any one of the three as a priority, as treatment continues, the hierarchy reduces but anytime during treatment a referral back and forth may be essential and mandatory.
Figure 2: Modes of interdisciplinary communication

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Each treating dentist should be aware of the earlier dentists' approaches and outcomes. Also should be aware of the stage at which the patient needs to be referred back. This will ensure satisfactory outcomes. Every act of communication is an act of translation. Thus the golden rule, lies in transparent translations.

Needless to say, of utmost importance is the flowing communication of records and information among the different specialties. Diagnosis, treatment planning and management are all bettered when the right information is with the right person. "All's well that ends well."

Taking an insight into the future, well-maintained records and established communication, can play a significant role in the prevention. Globalization would be the target! It might not seem such big a deal, but we could prevent even the bigger disease with the right records. "Research" is the foundation of not only, new developments, but also comparing what "was" to what "could be." Well-developed communication and proper records can go a long way in promoting better research by engaging in retrospective studies, which could entail a broader, more comprehensive vision.

Thus keeping in mind, the bigger picture, simplicity in record collection, and effortless communication, in interdisciplinary dentistry, is the key to a successful holistic dental practice. To conclude, we dentists best work as a team and "good teams become great ones, when the members trust each other enough, to surrender the 'me' for the 'we'."

 
   References Top

1.Lawney M. For the record. Understanding patient recordkeeping. N Y State Dent J 1998;64:34-43.  Back to cited text no. 1
    
2.Charangowda BK. Dental records: An overview. J Forensic Dent Sci 2010;2:5-10.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Heid DW, Chasteen J, Forrey AW. The electronic oral health record. J Contemp Dent Pract 2002;3:43-54.  Back to cited text no. 3
    
4.Schleyer TK. Dental informatics: A work in progress. Adv Dent Res 2003;17:9-15.  Back to cited text no. 4
    
5.Kahng LS. Patient-dentist-technician communication within the dental team: Using a colored treatment plan wax-up. J Esthet Restor Dent 2006;18:185-93.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]


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