Comparing Legal Compliance of Electronic and Handwritten Records

One motivating factor for electronic record implementation may be the potential for automated compliance with legal and institutional requirements. Traditional dental records often suffer from illegible handwriting, lack of updated histories, and omitted treatment plans. Do electronic records improve compliance? The paper summarized here looked at a limited retrospective study of one hundred records generated by four U.K. dental students required to keep both written and electronic records (utilizing the SALUD system) in their fourth year of study. The records were evaluated for legal and desirable traits by one head clinician. Similar patient record requirements exist throughout Europe and North America, giving this study broad application.  Students were not aware that their records would be assessed in this way at the time of documentation.

Electronic records showed a significant improvement over handwritten records in the legal requirements of checked medical history, correct anesthetic record, recorded recommendations to the patient, and identifiable signature. There was no significant difference in the recording of dates and the use of ambiguous abbreviations, and minimal difference in the legibility of entries, patient identification, and a recording of procedures. In desirable characteristics electronic records showed improved recording of corrections and investigative reports. Reminders for follow-up visits were actually better in handwritten records.

In most cases, improved or decreased compliance was directly related to the presence or absence of automatic functions of the system. Patient identification and identifiable authorship and signatures were all elements of the SALUD program. As well, computer generated notes always show a line through corrections if they are changed after saving the record. Reminders were presumably not automatically generated, and their use frequently suffers in computerized records if defined protocols are not in place.

Improved compliance with legal regulations and desirable record traits eases legal defense and continuity of care, particularly in environments with multiple caretakers.

Lessons Learned:

  • Computerized records induce higher compliance with legal requirements for record keeping through automated functions.
  • Compliance can be increased by adding discrete fields to the record, such as “recommendations to patient.”
  • Reminders for follow-up visits may suffer in computerized systems if not automatically generated.
  • Computerized records provide better continuity of care and legal defense.

McAndrew, R., Ban, J. & Playle, R. (2012) A comparison of computer- and hand-generated clinical dental notes with statutory regulations in record keeping. European Journal of Dental Education 16(1): 117-121. doi 10.1111/j.1600-0579.2011.00684.x