Objective Approximately 25 percent of all general dentists practicing in the U.S. use a computer in the dental operatory. Only 1.8 percent maintain completely electronic records. Anecdotal evidence suggests that dental computer-based patient records (CPR) do not represent clinical information with the same degree of completeness and fidelity as paper records. The objective of this study was to develop a basic content model for clinical information in paper-based records and examine its degree of coverage by CPRs.

Design We compiled a Baseline Dental Record (BDR) from a purposive sample of 10 paper record formats (two from dental schools and four each from dental practices and commercial sources). We extracted all clinical data fields, removed duplicates and organized the resulting collection in categories/subcategories. We then mapped the fields in four market-leading dental CPRs to the BDR.

Measurements We calculated frequency counts of BDR categories and data fields for all paper- and computer-based record formats, and cross-mapped information coverage at both the category and data field level.

Results The BDR had 20 categories and 363 data fields. On average, paper records and CPRs contained 14 categories, and 210 and 174 fields, respectively. Only 72, or 20 percent, of the BDR fields occurred in five or more paper records. Categories related to diagnosis were missing from most paper- and computer-based record formats. CPRs rarely used the category names and groupings of data fields common in paper formats.

Conclusion Existing paper records exhibit limited agreement on what information dental records should contain. CPRs only cover this information partially, and may thus impede the adoption of electronic patient records.