How patients describe their diagnosis compared to clinical documentation

Kelly Gleason; Maria R. Dahm

doi:10.1515/dx-2021-0070

Article

How patients describe their diagnosis compared to clinical documentation

Kelly Gleason and Maria R. Dahm

Published/Copyright: August 16, 2021

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From the journal Diagnosis Volume 9 Issue 2

Abstract

Objectives

To explore how patients describe their diagnoses following Emergency Department (ED) discharge, and how this compares to electronic medical record (EMR) documentation.

Methods

We conducted a cohort study of patients discharged from three EDs. Patients completed questionnaires regarding their understanding of their diagnosis. Inclusion criteria: adult ED patients aged 18 and older seen within the last seven days. We independently compared patient-reported new diagnoses following discharge to EMR-documented diagnoses regarding diagnostic content (identical, insignificantly different, different, not enough detail) and the level of technical language in diagnostic description (technical, semi-technical, lay).

Results

The majority of participants (n=95 out of 137) reported receiving a diagnosis and stated the given diagnosis. Of those who reported their diagnosis, 66%, were females (n=62), the average age was 43 (SD 16), and a fourth (n=24) were Black and 66% (n=63) were white. The majority (84%) described either the same or an insignificantly different diagnosis. For 11% the patient-reported diagnosis differed from the one documented. More than half reported their diagnosis using semi-technical (34%) or technical language (26%), and over a third (40%) described their diagnosis in lay language.

Conclusions

Patient-reported diagnoses following ED discharge had moderate agreement with EMR-documented diagnoses. Findings suggest that patients might reproduce verbatim semi-technical or technical diagnoses they received from clinicians, but not fully understood what the diagnosis means for them.

Keywords: health communication; patient-centered care; patient-provider communication; patient-report

Corresponding author: Kelly Gleason, RN, PhD, School of Nursing, Johns Hopkins University, 525 N. Wolfe Street, Baltimore, MD, 21225, USA, Phone: 708-334-4876, E-mail: kgleaso2@jhmi.edu

Funding source: Gordon and Betty Moore Foundation doi.org/10.13039/100000936

Funding source: NIH NCATS Institutional Career Development Core

Award Identifier / Grant number: KL2 TR003099

Funding source: NIH NCATS Johns Hopkins Institute for Clinical and Translational Research

Award Identifier / Grant number: UL1TR003098

Funding source: AHRQ A Human Factors and Systems Approach for Understanding the Diagnostic Process and Associated Safety Hazards in the Emergency Department

Award Identifier / Grant number: R01 HS 027198

Research funding: K. Gleason receives funding from the following sources: NIH NCATS Institutional Career Development Core, KL2 TR003099, NIH NCATS Johns Hopkins Institute for Clinical and Translational Research, UL1TR003098, AHRQ A Human Factors and Systems Approach for Understanding the Diagnostic Process and Associated Safety Hazards in the Emergency Department, R01 HS 027198, and the Gordon and Betty Moore Foundation (Developing a Patient-Reported Measure Set for Diagnostic Excellence). The funding organizations played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
Author contributions: KG and MD made substantial contributions to the conception and design of the work, and the analysis and interpretation of data. KG led the data acquisition. KG drafted the original manuscript and MD revised critically for important intellection content. KG and MD both gave final approval of the version to be published. KG and MD agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Competing interests: KG and MD have no competing interests to report.
Informed consent: All study participants provided informed consent.
Ethical approval: The Johns Hopkins Institutional Review Board approved this study (JHU IRB00202800). The research complied with all relevant national regulations, was in accordance with tenets of the Helsinki Declaration, and institutional policies for human subjects research.

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Received: 2021-05-25

Accepted: 2021-07-28

Published Online: 2021-08-16

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Articles in the same Issue

https://doi.org/10.1515/dx-2021-0070

Keywords for this article

health communication; patient-centered care; patient-provider communication; patient-report