Abstract
62 Background: To improve care for side effects and coordinate follow up, SCPs should correctly and thoroughly report details regarding diagnosis and treatment. However, literature is lacking regarding SCP accuracy and completeness. We audited SCPs for errors and omissions, as part of a clinical trial conducted at two cancer centers. Methods: SCPs were prepared for Stage 0-3 breast cancer patients by 1 of 2 methods, which was based on the standard of care at each center: 1) EHR-based: auto-populated using data entered into the EHR by oncologists for clinical use. SCP finalized by oncologist or advanced practice provider; and 2) Manual entry: prepared by an RN using manual transfer of clinical data into software program. Each participant’s clinical data was abstracted from her chart, with audit and cross-check against each SCP. In the case of discrepancies, oncologists reviewed the chart and adjudicated the “correct” information, as well as completeness and error. Omissions were defined by missing SCP information required per IOM recommendations; errors were defined as data reported in the SCP that did not match the chart. Results: Two sites enrolled 128 women between 11/2013-12/2014; 80 received EHR-based vs 41 manual SCPs. Omissions: 24 (30%) EHR-based versus 6 (15%) manual SCPs contained at least 1 omission. Omissions included failure to provide some dates and specific axillary surgery type (sentinel vs axillary) for EHR-based SCPs and failure to specify receptors for manual SCPs. Errors: 7 (9%) EHR-based versus 19 (46%) manual SCPs contained at least one error. The majority of EHR-based SCP errors were minor discrepancies in dates. Errors in manual SCPs included chemotherapy regimen, incorrect receptors, incorrect stage and axillary surgeries; stage and surgery errors were affected by poor fit with templated SCP fields. Conclusions: Little is known about SCP accuracy and completeness. Manually prepared SCPs may have a higher rate of errors while EHR-based SCPs may have more omissions. Differences in preparation (site, training of preparer) could also account for these differences. In an era of required SCP provision, measures of SCP quality should be considered.
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