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Preferences in Oncology History Documentation Styles Among Clinical Practitioners
Daniel B Martin1,2, Peter D Stetson3, G Weldon Gilcrease4
1Department of Medicine, University of Washington Medical Center, Seattle, WA.
JCO Oncology Practice
|July 6, 2021
Summary
Clinicians prefer chronologic oncology histories over narrative ones for patient care coordination and note preparation. This structured format enhances usefulness, organization, comprehensibility, and succinctness.
Area of Science:
- Oncology
- Medical Informatics
- Clinical Documentation
Background:
- Clinical notes are vital for provider handoffs, especially in unplanned encounters.
- Organized oncology histories are crucial for effective care coordination.
- Understanding clinician preferences for history organization is essential.
Purpose of the Study:
- To compare clinician preferences for chronologic versus narrative oncology history formats.
- To evaluate reader preferences based on specific attributes like usefulness and organization.
Main Methods:
- A survey was administered to 562 clinicians from 19 National Comprehensive Cancer Network institutions.
- Clinicians compared consensus-derived real-world chronologic and narrative oncology histories.
- Histories were evaluated using semantic differential attributes; preferences for note preparation and basis for new notes were recorded.
Main Results:
- Clinicians preferred chronologic histories for preparing to see unknown patients (66%) and for their own note preparation (77%).
- Chronologic summaries were rated higher for usefulness, organization, comprehensibility, and succinctness.
- Narrative histories were favored for thoroughness, with open-ended comments highlighting the value of social determinants of health content.
Conclusions:
- A chronologic oncology history format is preferred by clinicians over a concise narrative format.
- Further research is needed to optimize chronologic documentation structure and content for oncology patients.
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