O R I G I N A L R E S E A R C H Analysis of clinical records of dental patients attending Jordan University Hospital: Documentation of drug prescriptions and local anesthetic injections Najla Dar-Odeh1 Soukaina Ryalat1 Mohammad Shayyab1 Osama Abu-Hammad2 1Department of Oral and Maxillofacial Surgery Oral Medicine and Periodontics, Faculty of Dentistry, University of Jordan, Jordan; 2Department of Prosthetic Dentistry, Faculty of Dentistry, University of Jordan, Jordan Correspondence: Najla Dar-Odeh Department of Oral and Maxillofacial Surgery Oral Medicine and Periodontics, Faculty of Dentistry, University of Jordan, Jordan Tel +96 2 6535 5000 Ext 23594 Fax +96 2 6515 3783 Email najla_dar_odeh@yahoo.com Objectives: The aim of this study was to analyze clinical records of dental patients attending the Dental Department at the University of Jordan Hospital: a teaching hospital in Jordan. Analysis aimed at determining whether dental specialists properly documented the drug prescriptions and local anesthetic injections given to their patients. Methods: Dental records of the Dental Department at the Jordan University Hospital were reviewed during the period from April 3rd until April 26th 2007 along with the issued prescrip- tions during that period. Results: A total of 1000 records were reviewed with a total of 53 prescriptions issued during that period. Thirty records documented the prescription by stating the category of the prescribed drug. Only 13 records stated the generic or the trade names of the prescribed drugs. Of these, 5 records contained the full elements of a prescription. As for local anesthetic injections, the term “LA used” was found in 22 records while the names and quantities of the local anesthetics used were documented in only 13 records. Only 5 records documented the full elements of a local anesthetic injection. Conclusion: The essential data of drug prescriptions and local anesthetic injections were poorly documented by the investigated group of dental specialists. It is recommended that the administration of the hospital and the dental department implement clear and ﬁrm guidelines for dental practitioners in particular to do the required documentation procedure. Keywords: dental records, documentation, prescriptions, local anesthesia Introduction Dentists prescribe certain drugs for a number of conditions such as: orofacial pain, oral infections, oral ulceration, dry mouth and nutritional deﬁciencies. Moreover, local anesthetic injections are administered by dentists for intraoperative pain management and less commonly for diagnostic purposes. Although the number of these drugs may seem to be limited compared to those prescribed by other health care providers, the use of these drugs has important implications and extreme care should be taken upon prescribing to make the best use of these drugs and prevent their side effects. Since drug use – either by prescription or administration – might be associated with certain systemic complications, all drug prescriptions and local anesthetic injections should be documented in patients’ records. Antibiotic use is sometimes associated with unfavorable side effects. A serious side effect which is a major concern worldwide is the emergence of new multidrug-resistant bacteria. This has escalated at an alarming rate (Epstein et al 2000). Resistance to antibiotics among bacteria of the oral microﬂora was shown to be increasing as well (ADA 2004). Therapeutics and Clinical Risk Management 2008:4(5) 1111–1117 © 2008 Dar-Odeh et al, publisher and licensee Dove Medical Press Ltd.This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. 1111