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64385 Patient Reports of New Diagnosis Compared to Electronic Medical Record Documentation following Emergency Department Visit
ABSTRACT IMPACT: We conducted a study to understand how a patient’s report of a new diagnosis compares with what was documented in the electronic medical record, since it is critical to the diagnostic process that the patient both understands and agrees with a new diagnosis. OBJECTIVES/GOALS: We sou...
Autores principales: | , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
Cambridge University Press
2021
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8828022/ http://dx.doi.org/10.1017/cts.2021.735 |
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author | Gleason, Kelly Peterson, Susan Himmelfarb, Cheryl Newman-Toker, David |
author_facet | Gleason, Kelly Peterson, Susan Himmelfarb, Cheryl Newman-Toker, David |
author_sort | Gleason, Kelly |
collection | PubMed |
description | ABSTRACT IMPACT: We conducted a study to understand how a patient’s report of a new diagnosis compares with what was documented in the electronic medical record, since it is critical to the diagnostic process that the patient both understands and agrees with a new diagnosis. OBJECTIVES/GOALS: We sought feedback on patient’s understanding of their diagnosis and health status follow Emergency Department discharge. We compared patient report of a new diagnosis to documentation in the electronic medical record. METHODS/STUDY POPULATION: To compare patient reported diagnoses to documented diagnoses, we employed a longitudinal cohort study design at 3 of emergency departments in an academic health system in the Mid-Atlantic. Patients consented to complete questionnaires regarding their understanding of their diagnosis and/or follow-up steps and their health status at 2 weeks, 1 month, and 3 months following emergency department discharge. Inclusion criteria: adult ED patients aged 18 and older seen within the last 7 days with one or more of the following common chief complaints: chest pain, upper back pain, abdominal pain, shortness of breath/cough, dizziness, and headache. We compared patient report of a new diagnosis following discharge to documentation in the electronic medical record. RESULTS/ANTICIPATED RESULTS: Of the sample recruited (n=137), the majority were women (66%, n=91), the average age was 42 (SD 16). A third (n=45) were black and 56% (n=76) were white. The majority of participants (84%, n=115) reported that they either understood the diagnosis they received on ED discharge, or were not given a diagnosis but they understood follow-up steps. At two weeks following discharge, 25% of participants (n=36) had a new diagnosis identified after discharge and 33% (n=45) reported that their health status stayed the same or worsened. There was 85% agreement (kappa 0.49) between patient report of a new diagnosis and a new diagnosis identified in the electronic medical record. Only one of the participants who reported a new diagnosis also reported seeking healthcare outside of the health system. DISCUSSION/SIGNIFICANCE OF FINDINGS: Patient report of a new diagnosis following emergency department discharge had moderate agreement with new diagnoses identified in the electronic medical record, and differences in agreement were not explained by outside healthcare visits. |
format | Online Article Text |
id | pubmed-8828022 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2021 |
publisher | Cambridge University Press |
record_format | MEDLINE/PubMed |
spelling | pubmed-88280222022-03-04 64385 Patient Reports of New Diagnosis Compared to Electronic Medical Record Documentation following Emergency Department Visit Gleason, Kelly Peterson, Susan Himmelfarb, Cheryl Newman-Toker, David J Clin Transl Sci Translational Science, Policy, & Health Outcomes Science ABSTRACT IMPACT: We conducted a study to understand how a patient’s report of a new diagnosis compares with what was documented in the electronic medical record, since it is critical to the diagnostic process that the patient both understands and agrees with a new diagnosis. OBJECTIVES/GOALS: We sought feedback on patient’s understanding of their diagnosis and health status follow Emergency Department discharge. We compared patient report of a new diagnosis to documentation in the electronic medical record. METHODS/STUDY POPULATION: To compare patient reported diagnoses to documented diagnoses, we employed a longitudinal cohort study design at 3 of emergency departments in an academic health system in the Mid-Atlantic. Patients consented to complete questionnaires regarding their understanding of their diagnosis and/or follow-up steps and their health status at 2 weeks, 1 month, and 3 months following emergency department discharge. Inclusion criteria: adult ED patients aged 18 and older seen within the last 7 days with one or more of the following common chief complaints: chest pain, upper back pain, abdominal pain, shortness of breath/cough, dizziness, and headache. We compared patient report of a new diagnosis following discharge to documentation in the electronic medical record. RESULTS/ANTICIPATED RESULTS: Of the sample recruited (n=137), the majority were women (66%, n=91), the average age was 42 (SD 16). A third (n=45) were black and 56% (n=76) were white. The majority of participants (84%, n=115) reported that they either understood the diagnosis they received on ED discharge, or were not given a diagnosis but they understood follow-up steps. At two weeks following discharge, 25% of participants (n=36) had a new diagnosis identified after discharge and 33% (n=45) reported that their health status stayed the same or worsened. There was 85% agreement (kappa 0.49) between patient report of a new diagnosis and a new diagnosis identified in the electronic medical record. Only one of the participants who reported a new diagnosis also reported seeking healthcare outside of the health system. DISCUSSION/SIGNIFICANCE OF FINDINGS: Patient report of a new diagnosis following emergency department discharge had moderate agreement with new diagnoses identified in the electronic medical record, and differences in agreement were not explained by outside healthcare visits. Cambridge University Press 2021-03-30 /pmc/articles/PMC8828022/ http://dx.doi.org/10.1017/cts.2021.735 Text en © The Association for Clinical and Translational Science 2021 https://creativecommons.org/licenses/by/4.0/This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited. |
spellingShingle | Translational Science, Policy, & Health Outcomes Science Gleason, Kelly Peterson, Susan Himmelfarb, Cheryl Newman-Toker, David 64385 Patient Reports of New Diagnosis Compared to Electronic Medical Record Documentation following Emergency Department Visit |
title | 64385 Patient Reports of New Diagnosis Compared to Electronic Medical Record Documentation following Emergency Department Visit |
title_full | 64385 Patient Reports of New Diagnosis Compared to Electronic Medical Record Documentation following Emergency Department Visit |
title_fullStr | 64385 Patient Reports of New Diagnosis Compared to Electronic Medical Record Documentation following Emergency Department Visit |
title_full_unstemmed | 64385 Patient Reports of New Diagnosis Compared to Electronic Medical Record Documentation following Emergency Department Visit |
title_short | 64385 Patient Reports of New Diagnosis Compared to Electronic Medical Record Documentation following Emergency Department Visit |
title_sort | 64385 patient reports of new diagnosis compared to electronic medical record documentation following emergency department visit |
topic | Translational Science, Policy, & Health Outcomes Science |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8828022/ http://dx.doi.org/10.1017/cts.2021.735 |
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