Data Quality of Chemotherapy-Induced Nausea and Vomiting Documentation

Abstract

Objective The objective of the study was to characterize the completeness and concordance of the electronic health record (EHR) documentation of cancer symptoms among multidisciplinary health care professionals. Methods We examined the EHRs of children, adolescents, and young adults who received highly emetogenic chemotherapy and characterized the completeness and concordance of chemotherapy-induced nausea and vomiting (CINV) documentation by clinician type and by the International Classification of Diseases 10th Revision (ICD-10) coding choice. Results The EHRs of 127 patients, comprising 870 patient notes, were abstracted and reviewed. A CINV assessment was documented by prescribers in 75% of patients, and by nurses in 58% of patients. Of the 60 encounters where both prescribers and nurses documented, 72% agreed on the presence/absence of CINV. Conclusion Most patients receiving highly emetogenic chemotherapy had a documented assessment of CINV; however, many had incomplete or discordant documentation of CINV from different providers by role, implying the importance of incorporating pragmatic knowledge of EHR documentation patterns among multidisciplinary health professionals for EHR phenotyping and clinical decision support systems directed toward cancer-related symptom management.

Digital Health Data Quality Issues: Systematic Review

“…In total, 30 subthemes were identified and grouped into 6 DQ dimensions: accuracy, consistency, completeness, contextual validity, accessibility, and currency ( Table 1 ; Multimedia Appendix 6 [ 8 - 12 , 14 - 16 , 18 - 22 , 31 - 62 , 67 , 69 , 71 , 72 , 76 , 79 - 168 ]). Consistency (164/227, 72.2%), completeness (137/227, 60.4%), and accuracy (123/227, 54.2%) were the main DQ dimensions.…”

“…Positive perspectives pertaining to data completeness focus on the level of completeness, with studies reporting relatively high completeness rates in health data sets [ 34 , 38 , 80 , 94 , 95 , 170 ]. For data to be considered complete, it needs to be captured at sufficient breadth and depth over time [ 12 , 18 ].…”

“…This resulted in a consolidated set of 6 DQ dimensions (accuracy, consistency, completeness, contextual validity, accessibility, and currency). Multimedia Appendix 3 [ 9 , 12 , 13 , 15 , 16 , 18 , 19 , 21 , 31 - 65 ] provides an example of how the open codes were reflected in the subthemes and themes.…”

Improving infectious adverse event reporting for children and adolescents enrolled in clinical trials for acute lymphoblastic leukemia: A report from the Children's Oncology Group

“…Closely following the CTCAE definitions can be challenging when there is incomplete or conflicting documentation of clinical events within the patient medical record, the CTCAE lacks clinically recognized entities, such as culture-negative sepsis, or when its use of AE terms differs from how such terms are used in common clinical practice. 21,22 For example, grade 3 sepsis is defined in CTCAE as a positive blood culture in the presence of any systemic symptom or sign, whereas many clinicians reserve the use of the term "sepsis" to denote clinical instability. 18 Further, the number of AEs defined within CTCAE has markedly increased over successive versions.…”

Compreensão dos adolescentes sobre eventos adversos relacionados à quimioterapia: um estudo de elicitação de conceitos

“…Os adolescentes tenderam a identificar imediatamente os sintomas físicos, como náuseas, vômitos e dor, como os EAs mais problemáticos relacionados aos regimes quimioterápicos. Embora este estudo não tenha analisado a prevalência de EAs, nossos achados corroboram a literatura sobre o assunto, que indica esses sintomas físicos como alguns dos EAs mais frequentes e incômodos para essa população (25)(26)(27) . Além disso, as entrevistas permitiram aos pesquisadores analisar e relatar o vocabulário que os adolescentes utilizam para descrever tais eventos.…”