Does Clinical Documentation Reflect How Parents and Clinicians Share Decisions About Surgery?

Area of Science:

• Pediatric Surgery
• Health Communication
• Shared Decision-Making

Background:

• Shared decision-making (SDM) is widely accepted in clinical practice.
• The reflection of core SDM elements in clinical documentation remains unclear.
• This gap is critical in pediatric surgery, where parents act as proxy decision-makers.

Purpose of the Study:

• To analyze how parental concerns and preferences are reflected in clinical documentation during pediatric surgical encounters.
• To assess the frequency, content, and timing of these elements in verbal communication versus medical records.

Main Methods:

• Analysis of transcribed audio-recorded outpatient encounters for pediatric surgical evaluations.
• Coding of visit transcripts and corresponding medical documentation for parental concerns and preferences.
• Assessment of verbal communication and written records for expressed elements of SDM.

Main Results:

• Nearly half of encounters involved discussions of parental concerns (42%) and preferences (45%).
• Concerns focused on symptoms and were raised throughout visits; preferences centered on treatment decisions, often later in visits.
• Approximately half of all unique stated concerns (46%) and preferences (49%) were documented in medical records.

Conclusions:

• Parental concerns and preferences discussed in pediatric surgical encounters are frequently omitted from clinical documentation.
• Consistent documentation of family perspectives can improve transparency and communication.
• Enhanced documentation supports high-quality, patient- and family-centered care.