Is Documentation Reflective of Parent-Clinician Communication in Pediatric Surgical Consultations?

Abstract

Background Shared Decision-Making (SDM) is a collaborative process where patients and clinicians work together to determine a treatment plan, balancing evidence-based medicine with patient values. Little is known about how SDM is documented by clinicians in the Electronic Medical Record (EMR). Understanding how patient preferences are reflected in clinical documentation is important as clinicians strive to make care more patient-centered. This study seeks to evaluate whether clinical documentation is reflective of verbal communication in pediatric clinical encounters. Methods This Mixed Methods Sequential Exploratory Analysis included 109 pediatric surgical consultations. For each encounter, the transcript of the verbal clinician-family communication was descriptively evaluated for elements of SDM: discussion of risks/benefits/alternatives, parental preferences, and expression of parental concern. Next, the corresponding EMR documentation was evaluated for these elements. Qualitative methods were used to describe similarities and differences of these elements in both types of communication. A basic descriptive quantitative analysis was conducted to further describe the similarities/differences between these two types of communication describing the same clinical encounter. Results In the discussion of risks/benefits/alternatives, the EMR documentation for 48% of encounters used a standard dot phrase, which often differed from what was discussed verbally. Common discrepancies also included a parental preference being documented in the EMR when no preference was verbally expressed by the parent, occurring in 12% of consultations. The opposite was also seen: in 14% of consultations, a parental preference was expressed but was not documented. Overall, expression of parental concern was infrequent, occurring in 30% of the consultations. Of the 34 parental concerns that were expressed, only 21% were documented. Conclusion In conclusion, there are substantial discrepancies between what is verbally communicated in pediatric surgical encounters and what is subsequently documented in EMR documentation. As clinicians evolve in delivering patient-centered care, understanding how patient perspectives are reflected in medical documentation could significantly impact clinical practice, informing interventions to make documentation more inclusive of patient values. This research is particularly significant as patient care is becoming more transparent with increased patient access to their EMR, emphasizing the importance of understanding whether SDM is accurately reflected in clinical documentation.