Table 1.
Data abstraction guidelines were developed and used to abstract information from the medical consult forms.
| Information item | Description and example | |
|---|---|---|
| Patient information | ||
| 1 | Record ID | |
| 2 | Age | Patient age at time of encounter; difference between the date of birth and the date medical consult was sent to medical provider |
| 3 | Gender | Listed in the electronic dental record (i.e., Male, Female, Unknown) |
| Reason for medical consult | ||
| 4 | Reason for the medical consult | Specific or implied reason written on the medical consult form |
| 5 | Medical provider specialty | i.e., Family Practice, Internal Medicine, Cardiology |
| 6 | Medical provider address | Private practice or facility address |
| Information reported by dental providers in the medical consult form | ||
| 5 | Dental conditions/diagnoses | i.e., abscess, tooth pain |
| 6 | Dental treatments | i.e., course of treatment, type of treatment, etc. |
| 7 | Medication to be used during dental treatment | i.e., local anesthetic |
| 8 | Medication to be used after dental treatment | i.e., pain medication |
| 9 | Medical conditions and medications as reported by the patient | Any medical and medication information provided by the patient |
| Information requested by dental providers | ||
| 10 | Medication history of the patient | i.e., pain medication, list of medication/s antihypertensive medication, etc. |
| 11 | Medical condition(s) of the patient | Current medical status, condition(s) status and laboratory and/or diagnostic reports (i.e., medical history, cardiac status, HbA1c, viral load, CD4 count, echocardiogram report, recommendations etc.) |
| Information reported by physicians in the returned medical consult form | ||
| 12 | Medical condition(s) of the patient | Any medical information regarding a patient's condition(s) |
| 13 | Medication history | Any medication(s) the patient is currently prescribed, for example, anticoagulant medication |
| 14 | Contradictions for dental treatment | recommendations and medical clearance (i.e., antibiotic prophylaxis, contraindications, medical clearance etc.) |
| Medical consult response time | ||
| 15 | Number of days taken for the medical provider's response to medical consult | difference between the date of sending medical consult and date when medical consult was scanned into patient record (when available for dental provider to view information) |
| Miscellaneous | ||
| 16 | Complete patient health record provided | Medical provider sent complete patient record without responding to dental provider's questions |