Medical Student University of Texas Southwestern Medical School Dallas, Texas
Introduction: Little is known about how patient/family concerns expressed during clinical encounters are documented. We evaluated how clinical documentation reflects clinician-family communication and shared decision-making in pediatric surgical encounters.
Methods: We evaluated transcripts of audio-recorded communication that occurred during consults for children undergoing evaluation for elective surgery (adenotonsillectomy, circumcision, hernia repair) and compared them to the corresponding EMR visit documentation (notes). Communication transcripts and notes were qualitatively analyzed for elements pertinent to SDM using thematic content analysis. Two independent reviewers coded all data. Four SDM elements were then enumerated, and discrepancies between the encounter transcript and documentation tabulated.
Results: 109 transcript-EMR dyads were analyzed (87 (%) tonsillectomy). We identified four predominant SDM thematic elements: discussion of risks/benefits, presentation of treatment alternatives, parental preferences, and parental concerns. Discrepancies related to alternatives were most common [documentation of alternative options present in notes but not discussed during encounter; more alternatives documented than actually discussed]. Similar discrepancies related to discussion of risks/benefits [documenting review of more risks than were actually discussed]. Some encounters showed a different preference documented than was expressed in the encounter, or showed a parental preference documented in the note that was never expressed. Additionally some transcripts showed parents expressing multiple concerns that were not documented by the clinician.
Conclusion: Clinical documentation does not consistently reflect clinician-family communication or SDM in pediatric surgical care. Findings imply opportunities for patient-centered clinical documentation innovations that broadly capture treatment plans discussed and patient/family preferences and concerns.