Concordance between patient reports of cancer-related symptoms and medical records documentation

Two sources of symptom data, patient report and medical records documentation, have been used in studies focusing on chronic conditions. The concordance of patient-reported cancer-related symptoms and clinician reports as documented in the medical records needs to be evaluated.

To compare patient reports with medical record documentation of 12 disease- and treatment-related symptoms for women with advanced breast cancer undergoing chemotherapy or hormonal therapy for cancer control.

Women (n=384) were recruited from 13 oncology clinics in the midwestern U.S. They completed telephone interviews at intake, five, and 11 weeks, where they reported the presence of 12 symptoms using a checklist. Medical records were abstracted when women completed the study. The concordance between patient reports and medical record documentation was assessed using percent agreement, kappa statistics, and McNemar's tests. Administration of medication for symptoms and patient characteristics were investigated in relation to the agreement of the two sources of data.

Poor to slight agreement was found, and disagreement was significant for all 12 symptoms. The concordance between symptom presence in the medical record and administration of medication for the management of those symptoms was moderate. Patient characteristics were not associated with agreement, except for age. The agreement was higher for older women for the symptom of mouth sores.

Medical records may not provide adequate documentation of symptoms, and collection of patient-reported symptom data from women with advanced breast cancer is critical to quality clinical management.