Assessing Perceptions of Positive and Negative Content within Goals of Care Notes

Area of Science:

• Medical Documentation
• Patient-Centered Communication
• Health Disparities

Background:

• Clinician documentation of negative content in electronic health records (EHRs) is a recognized issue.
• Goals of Care Conversation (GOCC) notes are critical for documenting patient wishes.

Purpose of the Study:

• To assess community members' and clinicians' perceptions of negative content within GOCC notes.
• To identify discrepancies in understanding what constitutes negative content in these important documents.

Main Methods:

• A mixed-methods study involving 12 participants (6 community members, 6 clinicians) across 14 hospitals.
• Thematic analysis was used to analyze perceptions of positive, neutral, and negative content within 65 GOCC notes.

Main Results:

• Both groups agreed on positive content (e.g., kind language, patient values).
• Significant differences emerged regarding negative content: community members cited understanding limitations, poor health descriptions, and lack of empathy.
• Clinicians identified poor writing, missing information, and judgmental descriptions as negative content.

Conclusions:

• There is low agreement between community members and clinicians on what constitutes negative content in GOCC notes.
• Findings highlight the need for clearer guidelines to improve GOCC note documentation for all stakeholders.
• Improved documentation can enhance communication and shared decision-making in healthcare.