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Content Analysis of Serious Illness Conversation Documentation: Structured vs. Free-Text Information
Brigitte N Durieux1, Seth N Zupanc2, Elise C Tarbi3
1Department of Psychosocial Oncology and Palliative Care, (B.N.D, S.N.Z, J.R.L, C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA.
Journal of Pain and Symptom Management
|July 17, 2024
Summary
Documentation of serious illness conversations varies between structured tabs and clinical notes in electronic health records. Consolidating these sources is recommended to improve patient care information retention.
Area of Science:
- Medical Informatics
- Health Services Research
- Oncology
Background:
- Effective documentation of serious illness conversations is crucial for aligning patient care with their values.
- Electronic health records (EHRs) offer multiple avenues for documenting these critical discussions.
Purpose of the Study:
- To characterize and compare serious illness conversations documented via structured tabs versus free-text clinical notes within the EHR.
- To understand how different documentation methods impact the captured content of these conversations.
Main Methods:
- Content analysis of serious illness conversations from 150 advanced cancer patients documented in EHRs.
- Development of a codebook by a multidisciplinary team to classify conversation content.
- Mixed deductive-inductive coding applied to structured tabs and free-text notes.
Main Results:
- Structured tabs more frequently captured patient fears/worries and illness understanding.
- Free-text notes more often documented treatment preferences, advance directive deliberations, function, and trade-offs.
- Documentation varied in length and detail, with notable contributions from palliative and social work clinicians.
Conclusions:
- The method of documenting serious illness conversations in the EHR influences the information captured.
- Consolidating documentation sources is essential for enhancing care quality and information retention.
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