How Do Clinicians Use Quotations in Goals of Care Notes?

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Quoting patients in electronic medical record (EMR) notes is controversial. Quotations may be used to promote accuracy in documentation. However they also may be used to cast skepticism on patient speech. Little is known about how quotations are used in EMR notes documenting goal of care (GOC) conversations. 1) How often are quotations used in GOC notes; 2) what content do clinicians quote; and 3) how does quotation use vary by clinician specialty and patient sociodemographic characteristics? This multihospital, cross-sectional study assessed quotation use in GOC notes for seriously ill adult patients hospitalized between July-October 2021. Quotation frequency was evaluated and thematic analysis was used to assess the content of language quoted in GOC notes. The odds of quotation use by clinician specialty and patient sociodemographic group were determined using multivariable logistic regression. Our review of 1003 GOC notes across fourteen hospitals found quotations were used in 32% of notes and were more often used by palliative clinicians when compared to non-palliative clinicians (38% vs. 21%, unadjusted OR 2.34, 95% CI 1.74-3.14, adjusted OR 2.62, 95% CI 1.66-4.13). Quotations were present more often in notes of Black versus White patients (41% vs. 30%, unadjusted OR 1.61, 95% CI 1.08-2.38, adjusted OR 1.73, 95% CI 1.11-2.71). The content of language included in quotations most often detailed patient feelings, family preferences, and patient discussion about death. This multicenter study found quotations were used in almost one-third of GOC notes, were used more often used by palliative versus non-palliative clinicians and were present more often in notes for Black versus White patients. Future research must explore clinician intentions in using quotations and identify whether quotation use may contribute to racial disparities in patient care.