Int J Med Inform - Development and initial validation of a content taxonomy for patient records in general dentistry.

Tópicos

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Resumo

JECTIVE: 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.CONCLUSION: 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.

Resumo Limpo

jectiv develop valid initi content taxonomi patient record general dentistrymethod phase obtain deidentifi patient record general dentist unit state phase extract individu data field inform item explicit label implicit unlabel record organ categori mirror origin field context phase refin raw list inform item elimin duplicatesredund focus general dentistri phase valid item regard inclus import use tworound delphi studi panel general dentist activ clinic practic educ researchresult analysi patient record dentist combin previous work yield raw list inform item refin reduc list item subsequ rate delphi panel final model contain item rate mandatori round final item accept round remain item initi list reject remain equivocalconclus ground realiti clinic practic propos content taxonomi repres signific advanc exist guidelin standard provid granular comprehens inform represent general dental patient record offer signific foundat asset implement interoper health inform technolog infrastructur general dentistri

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