RESUMO
Purpose: The purpose of this study was to evaluate the extent of concordance and significance of inaccuracies between a parent-reported medical history in a nonintegrated electronic dental record (EDR) and an integrated electronic health record (EHR). Methods: In a retrospective institutional review board chart review, a single trained examiner compared medical histories in an EDR with the same patient's history from an EHR for concordance in sociodemographic, medical condition, allergy, and medication variables deemed significant to dental care. Of 4,282 possible patient comparisons, 291 patients were randomly sampled and compared. Concordance between record types was generated for each variable using the EHR as the ideal standard. Data were analyzed using percent match comparison and logistic regression. Results: Only 10 of 45 variables (22 percent) met the standard to match. Present conditions were more likely to be unreported than falsely reported in the EDR (58 percent). Logistic regression revealed multiple significant associations between sociodemographic variables and concordance between the EDR and EHR on specific medical conditions and medications. Conclusions: Discrepancies exist between parent-reported medical histories (EDR) and composite health histories (EHR), with the potential to compromise patient safety and create an opportunity for medical error. Social determinants of health are associated with true-positive and true-negative reporting of medications and medical conditions. EHRs allow clinicians access to a greater depth of health history information in real time compared to nonintegrated health records, but medical history-taking skills should remain at the forefront of dental education and dental practice.
