Data Quality of Chemotherapy-Induced Nausea and Vomiting DocumentationFunding M.B. was supported by the National Institute of Nursing Research Training Grant (NR007969), the National Cancer Institute Training Grant (CA094061), and the Doctoral Degree Scholarship in Cancer Nursing (DSCN-18–068–01) from the American Cancer Society. C.W. was supported by the National Library of Medicine Grant (R01LM009886). R.S. was supported by the National Institute of Nursing Research of the National Institutes of Health under award number K24NR 018621. The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health or the American Cancer Society.
Objective The objective of the study was to characterize the completeness and concordance of the electronic health record (EHR) documentation of cancer symptoms among multidisciplinary health care professionals.
Methods We examined the EHRs of children, adolescents, and young adults who received highly emetogenic chemotherapy and characterized the completeness and concordance of chemotherapy-induced nausea and vomiting (CINV) documentation by clinician type and by the International Classification of Diseases 10th Revision (ICD-10) coding choice.
Results The EHRs of 127 patients, comprising 870 patient notes, were abstracted and reviewed. A CINV assessment was documented by prescribers in 75% of patients, and by nurses in 58% of patients. Of the 60 encounters where both prescribers and nurses documented, 72% agreed on the presence/absence of CINV.
Conclusion Most patients receiving highly emetogenic chemotherapy had a documented assessment of CINV; however, many had incomplete or discordant documentation of CINV from different providers by role, implying the importance of incorporating pragmatic knowledge of EHR documentation patterns among multidisciplinary health professionals for EHR phenotyping and clinical decision support systems directed toward cancer-related symptom management.
Protection of Human and Animal Subjects
Protection of human and animal subjects was followed according to the IRB. This study included data that had already been collected for clinical care of included patients, and all data were reported in aggregate to avoid any patient identifiers.
Received: 29 October 2020
Accepted: 02 March 2021
21 April 2021 (online)
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