Bernier Carney Katherine, Wilkes Jacob, Aderibigbe Tumilara, Stegenga Kristin, Spraker-Perlman Holly, Linder Lauri A
School of Nursing (K.B.C), University of Connecticut, Storrs, Connecticut, USA.
Intermountain Healthcare (J.W.), Salt Lake City, Utah, USA.
J Pain Symptom Manage. 2025 Apr;69(4):409-419.e1. doi: 10.1016/j.jpainsymman.2025.01.004. Epub 2025 Jan 16.
Children and adolescents with cancer experiencing complex symptoms can benefit from subspeciality palliative care. However, standardized methods of symptom documentation by pediatric palliative care teams are lacking. Understanding current approaches to symptom documentation will inform next steps to optimize symptom support.
To explore the documentation of symptom prevalence and characteristics in unstructured clinical notes by pediatric palliative care clinicians caring for children and adolescents with cancer.
We reviewed unstructured clinical notes documented by the pediatric palliative care team for 115 children and adolescents with cancer. Symptom-related data were abstracted and evaluated using content analysis based on the Memorial Symptom Assessment Scale 10-18 instrument items. We also evaluated documentation of severity and distress for six commonly experienced symptoms in pediatric cancer: difficulty sleeping; feelings of sadness; lack of energy; nausea/vomiting; pain; and worry.
We identified 1420 symptoms in 662 clinical notes for 106 patients. We identified a median of 5 individual symptoms (IQR = 3-8.5) per patient. Pain was the most frequently documented symptom (n = 79 patients, 74.5%). We identified at least one of the six commonly experienced symptoms in 88 patients (83%). Documentation of the associated severity and distress of these symptoms was inconsistent.
Palliative care clinicians routinely documented the co-occurrence of multiple complex symptoms experienced by children and adolescents with cancer. Unstructured progress notes captured evidence of symptom impact on daily life. Clinicians may benefit from a systematic approach to document symptoms in the clinical record which supports symptom identification and communication across clinical teams.
患有复杂症状的癌症儿童和青少年可从专科姑息治疗中受益。然而，儿科姑息治疗团队缺乏标准化的症状记录方法。了解当前的症状记录方法将为优化症状支持的下一步措施提供信息。
探讨为患有癌症的儿童和青少年提供护理的儿科姑息治疗临床医生在非结构化临床记录中对症状发生率和特征的记录情况。
我们回顾了儿科姑息治疗团队为115名患有癌症的儿童和青少年记录的非结构化临床记录。基于纪念症状评估量表10-18项条目，采用内容分析法提取并评估与症状相关的数据。我们还评估了儿科癌症中六种常见症状的严重程度和痛苦程度的记录情况：睡眠困难；悲伤情绪；缺乏精力；恶心/呕吐；疼痛；以及担忧。
我们在106名患者的662份临床记录中识别出1420种症状。我们确定每位患者的个体症状中位数为5种（四分位间距 = 3 - 8.5）。疼痛是记录最频繁的症状（n = 79例患者，74.5%）。我们在88名患者（83%）中识别出至少一种六种常见症状。这些症状相关严重程度和痛苦程度的记录并不一致。
姑息治疗临床医生常规记录了患有癌症的儿童和青少年所经历的多种复杂症状的同时出现情况。非结构化的病程记录捕捉到了症状对日常生活影响的证据。临床医生可能会从一种系统的方法中受益，即在临床记录中记录症状，这有助于临床团队之间的症状识别和沟通。
