The researchers found that at the participant level, 34 percent had different reporting of blurry vision between the ESQ and EMR. Likewise, documentation was not in agreement for reporting glare (48 percent), pain or discomfort (27 percent), and redness (25 percent). Discordance of symptom reporting was more frequently characterized by positive reporting on the ESQ and lack of documentation in the EMR. Return visits at which the patient reported blurry vision on the ESQ had increased odds of not reporting the symptom in the EMR compared with new visits.
"We found significant inconsistencies between symptom self-report on an ESQ and documentation in the EMR, with a bias toward reporting more symptoms via self-report. If the EMR lacks relevant symptom information, it has implications for patient care, including communication errors and poor representation of the patient's reported problems. The inconsistencies imply caution for the use of EMR data in research studies. Future work should further examine why information is inconsistently reported. Perhaps the implementation of self-report questionnaires for symptoms in the clinical setting will mitigate the limitations of the EMR and improve the quality of documentation," the authors write.
Valikodath NG, Newman-Casey PA, Lee PP, Musch DC, Niziol LM, Woodward MA.
Agreement of Ocular Symptom Reporting Between Patient-Reported Outcomes and Medical Records.
JAMA Ophthalmol. January 26, 2017. doi: 10.1001/jamaophthalmol.2016.5551.