Emotions documented in clinical notes: An interpretative descriptive study

Area of Science:

• Medical Informatics
• Palliative Care
• Qualitative Research

Background:

• Seriously ill patients and families have emotionally charged conversations with clinicians regarding care preferences.
• Understanding emotional distress is crucial for timely supportive care interventions.

Purpose of the Study:

• To investigate how clinicians document emotions in clinical notes for seriously ill patients.
• To identify the context in which emotions are recorded.

Main Methods:

• Qualitative interpretive descriptive study analyzing 500 clinical notes from seriously ill inpatients.
• Inductive analysis to identify emotion-related words and phrases.

Main Results:

• Emotions were documented in four categories: explicit/implicit emotions, social/interpersonal interactions, existential/spiritual emotions, and prognostic-related emotions.
• A novel lexicon of emotion and emotion-adjacent words was developed from the documented emotions.

Conclusions:

• Clinicians commonly document emotions arising from patient and family conversations.
• A clinical emotion lexicon can enhance electronic health records, aiding in the identification of emotional distress and supportive care needs.