Discrepancies in Communication Versus Documentation of Weight-Management Benchmarks

Abstract

To examine gaps in communication versus documentation of weight-management clinical practices, communication was recorded during primary care visits with 6- to 12-year-old overweight/obese Latino children. Communication/documentation content was coded by 3 reviewers using communication transcripts and health-record documentation. Discrepancies in communication/documentation content codes were resolved through consensus. Bivariate/multivariable analyses examined factors associated with discrepancies in benchmark communication/documentation. Benchmarks were neither communicated nor documented in up to 42% of visits, and communicated but not documented or documented but not communicated in up to 20% of visits. Lowest benchmark performance rates were for laboratory studies (35%) and nutrition/weight-management referrals (42%). In multivariable analysis, overweight (vs obesity) was associated with 1.6 more discrepancies in communication versus documentation (P = .03). Many weight-management benchmarks are not met, not documented, or performed without being communicated. Enhanced communication with families and documentation in health records may promote lifestyle changes in overweight children and higher quality care for overweight children in primary care.

Nurse Documentation of Child Weight-Related Health Promotion at Age Four in Sweden

“…Previous research showed that CHC nurses provide more information verbally in encounters with children and their families than what is documented in the record [16]. Differences between what is communicated and what is documented were found to be in both directions, i.e., what is communicated is not documented, and what is documented is not communicated [25]. The Patient Data Act [26] prescribes that CHC nurses have an obligation to document, and what is not documented did not occur.…”