Agreement between patient-reported symptoms and their documentation in the medical record

Serguei V. Pakhomov, Steven J. Jacobsen, Christopher G. Chute, Veronique Lee Roger

Research output: Contribution to journalArticle

123 Citations (Scopus)

Abstract

Objective: To determine the agreement between patient-reported symptoms of chest pain, dyspnea, and cough and the documentation of these symptoms by physicians in the electronic medical record. Methods: Symptoms reported on patient-provided information forms between January 1, 2006, and June 30, 2006, were compared with those identified by natural language processing of the text of clinical notes from care providers. Terms that represent the 3 symptoms were used to search clinical notes electronically with subsequent manual identification of the context (eg, affirmative, negated, family history) in which they occurred. Results were reported using positive and negative agreement, and kappa statistics. Results: Symptoms reported by 1119 patients age 18 years or older were compared with the non-negated terms identified in their clinical notes. Positive agreement was 74, 70, and 63 for chest pain, dyspnea, and cough, while negative agreement was 78, 76, and 75, respectively. Kappa statistics were 0.52 (95% confidence interval [CI] = 0.44, 0.60) for chest pain, 0.46 (95% CI = 0.37, 0.54) for dyspnea, and 0.38 (95% CI = 0.28, 0.48) for cough. Positive agreement was higher for older men (P >.05), and negative agreement was higher for younger women (P >.05). Conclusions: We found discordance between patient self-report and documentation of symptoms in the medical record. This discordance has important implications for research studies that rely on symptom information for patient identification and may have clinical implications that must be evaluated for potential impact on quality of care, patient safety, and outcomes.

Original languageEnglish (US)
Pages (from-to)530-539
Number of pages10
JournalAmerican Journal of Managed Care
Volume14
Issue number8
StatePublished - Aug 2008

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Documentation
Medical Records
documentation
pain
confidence
Chest Pain
Cough
Dyspnea
statistics
Confidence Intervals
genealogy
patient care
Natural Language Processing
physician
electronics
Electronic Health Records
Quality of Health Care
Patient Safety
Self Report
language

ASJC Scopus subject areas

  • Nursing(all)
  • Medicine(all)
  • Health(social science)
  • Health Professions(all)

Cite this

Agreement between patient-reported symptoms and their documentation in the medical record. / Pakhomov, Serguei V.; Jacobsen, Steven J.; Chute, Christopher G.; Roger, Veronique Lee.

In: American Journal of Managed Care, Vol. 14, No. 8, 08.2008, p. 530-539.

Research output: Contribution to journalArticle

Pakhomov, Serguei V. ; Jacobsen, Steven J. ; Chute, Christopher G. ; Roger, Veronique Lee. / Agreement between patient-reported symptoms and their documentation in the medical record. In: American Journal of Managed Care. 2008 ; Vol. 14, No. 8. pp. 530-539.
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