Analyzing Medication Documentation in Electronic Health Records: Dental Students' Self-Reported Behaviors and...

Area of Science:

• Dental Education
• Health Informatics
• Patient Safety

Background:

• Accurate medication documentation in electronic health records (EHRs) is crucial for patient safety and effective dental care.
• Dental students' understanding and application of medication history-taking practices are essential for their clinical competency.

Purpose of the Study:

• To evaluate dental students' perceptions and practices concerning medication documentation within the axiUm EHR system.
• To identify barriers affecting complete and accurate medication history recording by dental students.

Main Methods:

• A two-part study involving anonymous surveys of third- and fourth-year dental students and a retrospective review of patient EHRs.
• Survey assessed perceptions of medication history importance and self-reported documentation behaviors.
• EHR review analyzed documentation completeness and consistency for patient medications.

Main Results:

• A high percentage of students (90.4%) perceived medication history as vital for understanding patient conditions.
• However, complete medication documentation was low, with proper medication name recorded most often (93.6%) and potential oral effects least often (3.0%).
• Key barriers identified were patients' inability to recall medications (68.5%) and, to a lesser extent, EHR system limitations (14%).

Conclusions:

• While dental students value medication history, they often fail to appreciate the importance of all documentation elements.
• Incomplete medication documentation in EHRs remains a significant issue, highlighting a gap between perception and practice.
• Interventions are needed to improve comprehensive medication documentation skills among dental students.