Does the Medical Record Cover the Symptoms Experienced by Cancer Patients Receiving Palliative Care? A Comparison of the Record and Patient Self-Rating

Abstract

The aim of this study was to investigate the extent to which the symptoms experienced by advanced cancer patients were covered by the medical records. Fifty-eight patients participated in the study. On the day of first encounter with our palliative care department, a medical history was taken, and on this or the following day, the patients completed the EORTC Quality of Life Questionnaire (EORTC QLQ-C30), Edmonton Symptom Assessment System (ESAS), and Hospital Anxiety and Depression Scale (HADS). The symptomatology reported in the patient-completed questionnaires was compared with the symptomatology mentioned by the physician in the medical record. The analysis revealed good concordance concerning pain, but most other symptoms or problems were reported much more often by patients than by their doctors. Reasons for these discrepancies are discussed. It is suggested that the doctor's knowledge of the patient's symptomatology might gain from more systematic screening and transfer of information from patient self-assessment questionnaires to the medical records.

Is the high intensity symptoms experienced by patients admitted with chronic obstructive pulmonary disease documented by health professionals? - a prospective survey with comparison of patient reported outcomes and medical records

“…This is in concordance with Strömgren et al proclaiming that physical symptoms much more often are recognized when compared to psychological symptoms [24]. …”

“…The high level of recognition among the doctors of these main symptoms of COPD is expected in a specialized respiratory unit, and is much higher than what was found among doctors (46%) in specialized palliative cading to Strömgren et al [24]. …”

“…In alliance with previous studies [23,24], this study also accepts a symptom intensity of 2 in EORTC-QLQ-C15-PAL as a threshold and proclaims it our cut-off-value. All intensities> 2 will be regarded as high intensity.…”

“…It is presumed within oncology that doctors’ and nurses’ symptom recognition is a fundament for the palliative care offered, based on the assumption that if a symptom is not recognized and documented by health professionals, it is unlikely that it will be treated. Studies conducted within a population of patients with cancer shows a discrepancy between symptoms reported by patients and the extent to which they are acknowledged by health professionals [23,24]. This discrepancy reduces chances of symptom alleviation and subsequent increased quality of life [23–25].…”

“…In line with previous studies we wish to estimate ‘Doctor’s Symptom Recognition percentage’ (DSR) [24] and ‘Nurse’s Symptom Recognition percentage’ (NSR) [23], i.e., – the extend to which symptoms with high intensity experienced by admitted patients with COPD and described by either COPD assessment test (CAT) [28] or European Organisation for Research and Treatment for Cancer’s questionnaire reflecting palliative symptoms (EORTC-QLQ-C15-PAL) [29] are recognized by health professionals.…”