Pakhomov Serguei V, Jacobsen Steven J, Chute Christopher G, Roger Veronique L
Department of Pharmaceutical Care and Health Systems, University of Minnesota, 308 Harvard St, SE, 7-125F Weaver-Densford Hall, Minneapolis, MN 55401, USA.
Am J Manag Care. 2008 Aug;14(8):530-9.
To determine the agreement between patient-reported symptoms of chest pain, dyspnea, and cough and the documentation of these symptoms by physicians in the electronic medical record.
Symptoms reported on patient-provided information forms between January 1, 2006, and June 30, 2006, were compared with those identified by natural language processing of the text of clinical notes from care providers. Terms that represent the 3 symptoms were used to search clinical notes electronically with subsequent manual identification of the context (eg, affirmative, negated, family history) in which they occurred. Results were reported using positive and negative agreement, and kappa statistics.
Symptoms reported by 1119 patients age 18 years or older were compared with the nonnegated terms identified in their clinical notes. Positive agreement was 74, 70, and 63 for chest pain, dyspnea, and cough, while negative agreement was 78, 76, and 75, respectively. Kappa statistics were 0.52 (95% confidence interval [CI] = 0.44, 0.60) for chest pain, 0.46 (95% CI = 0.37, 0.54) for dyspnea, and 0.38 (95% CI = 0.28, 0.48) for cough. Positive agreement was higher for older men (P >.05), and negative agreement was higher for younger women (P >.05).
We found discordance between patient self-report and documentation of symptoms in the medical record. This discordance has important implications for research studies that rely on symptom information for patient identification and may have clinical implications that must be evaluated for potential impact on quality of care, patient safety, and outcomes.
确定患者报告的胸痛、呼吸困难和咳嗽症状与医生在电子病历中对这些症状的记录之间的一致性。
将2006年1月1日至2006年6月30日期间患者提供的信息表上报告的症状与通过对医疗服务提供者临床记录文本进行自然语言处理识别出的症状进行比较。使用代表这三种症状的术语对临床记录进行电子搜索，随后人工识别它们出现的上下文（如肯定、否定、家族史）。结果采用阳性和阴性一致性以及kappa统计量进行报告。
将1119名18岁及以上患者报告的症状与其临床记录中识别出的非否定术语进行比较。胸痛、呼吸困难和咳嗽的阳性一致性分别为74%、70%和63%，而阴性一致性分别为78%、76%和75%。胸痛的kappa统计量为0.52（95%置信区间[CI]=0.44，0.60），呼吸困难为0.46（95%CI=0.37，0.54），咳嗽为0.38（95%CI=0.28，0.48）。老年男性的阳性一致性较高（P>.05），年轻女性的阴性一致性较高（P>.05）。
我们发现患者自我报告与病历中症状记录之间存在不一致。这种不一致对依赖症状信息进行患者识别的研究具有重要意义，并且可能具有临床意义，必须评估其对医疗质量、患者安全和结局的潜在影响。
