Concordance Between Patient-Reported and Clinically Documented Symptoms in Acute Myeloid Leukemia.
Sena Chae, Jaewon Bae, Nayung Youn and 4 others
PMID 42341334WHAT IT FOUND
In 31 hospitalized adults with AML, drowsiness and sadness were often reported but rarely recorded in the chart.
Skin changes and swelling were recorded more often than patients reported them.
Key findings
0121 of 36 symptoms were documented less often than patients reported them.
02Drowsiness was reported by 27 participants but documented for only 5.
03Swelling of arms or legs was documented for 25 participants but reported by only 12.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The study included only 31 patients at one comprehensive cancer center, so the documentation patterns may not match other hospitals. Most participants were White and male, and non-English speakers and patients with cognitive impairment were excluded. Symptom extraction from nursing flow sheets was difficult because flow sheets are designed for routine assessments rather than detailed oncology symptoms. Clinical notes and flow sheets were written by multiple clinicians, so the study could not attribute each entry to one provider. The study measured agreement between patient reports and charts; it did not test whether better documentation changes treatment or outcomes.
The easy way to misread this
Do not conclude that poor documentation caused worse care or that clinicians ignored symptoms. The study compared patient reports with chart entries in 31 patients and did not measure treatment decisions or patient outcomes.