Forms and Consent

Standardized Adult and Pediatric Medical History and Dental Histories

The Data Standardization Committee has created standardized Adult and Pediatric Medical History and Dental History forms for COHRI schools to use.  COHRI schools using the forms should not change any of the question or answers and should use the same set-up for the questions, including reference codes, in the EPR form in axiUm.  This will allow for easy data mining.  Schools are free to add any questions to their own form and databases that they wish to ask at their school.  For further information please contact Nici Kimmes:  kimmes@ohsu.edu.

Standardized Problem List

COHRI adopted a minimal standardized problem list after a thoughtful process using its Quality Improvement (QI) workgroup. This group first gathered all problems that COHRI member institutions had loaded in AxiUm. Next the entire QI workgroup gathered in person and determined the major categories and a few sub-categories for the Problem List and determined which problems would fit under which category, identifying duplicates and eliminating terms that were not findings but rather diagnoses. A subgroup was appointed to finalize this exercise. The drafted initial Problem List was then validated using a Closed Card sorting exercise with the entire QI workgroup.

This first validated standardized Problem List allows COHRI members to document problems (findings) in a standardized way, which will facilitate retrieval of data for secondary data analysis. COHRI institutions are allowed to add problems (findings) and/or sub-categories, but cannot add new categories. COHRI strongly suggest not adding diagnoses to the problem list.

Access and use of our COHRI standardized Problem List can simply be obtained by contacting Elsbeth Kalenderian: Elsbeth_Kalenderian@hsdm.harvard.edu.

Standardized Dental Diagnostic Terminology

The DDS dental diagnostic terminology (formerly known as the EZCodes) consists of 1518 diagnostic terms subdivided into 17 categories and 106 sub-categories for easy retrieval. This will allow all of us to standardize how we document diagnoses and as such allow for better research capabilities. This terminology is protected through copyright, which means that no reproduction or use of this material is permitted without specific written permission.

Terminologies must evolve with the clinical domains. Our standardized diagnostic terminology undergoes annual review, which is informed by end-user input and continual literature review. Access and use of our standardized diagnostic terminology can simply be obtained by contacting Elsbeth Kalenderian: Elsbeth_Kalenderian@hsdm.harvard.edu. The DDS standardized diagnostic terminology are copywritten (© 2010 President and Fellows of Harvard College, the Board of Regents of the University of Texas System, Academic Centre for Dentistry Amsterdam and Regents of the University of California). Users agree not to alter the terminology but can request changes to future versions. These restrictions exist to ensure that the terminology remains standardized.

Standardized Caries Risk Assessment

The COHRI CAMBRA Workgroup has three items that can be obtained and used by COHRI member institutions. The workgroup has standardized the COHRI caries risk assessment tool and operationalized it in axiUm, called the COHRI CRA (long form). This is ideal for teaching purposes and for difficult caries risk determination. This CRA includes the best practices from many CRA forms and was developed by our workgroup. There is also a CAMBRA CRA CDS, Short form, which includes a clinical decision support feature that automatically determines caries risk. Simply answering the questions and pushing the calculate button determines caries risk for the patient. The workgroup has also developed a standardized CAMBRA prevention intervention, which is a table of agreed upon CAMBRA prevention interventions based on caries risk.

The COHRI CAMBRA Workgroup is open for membership for anyone interested in participating. The COHRI CAMBRA Workgroup is now focusing on usability testing of the caries risk assessment forms and dissemination of the caries risk forms and standardized preventive interventions.

To obtain the COHRI CRA Long Form or CRA CDS Short Form with clinical decision support and CAMBRA preventive interventions, please email your request AND your IT contact’s email to Joel White, whitej@dentistry.ucsf.edu. For further information and to become a member of the COHRI CAMBRA Workgroup, please contact: whitej@dentistry.ucsf.edu.