Abstract
Objectives: To explore how patients describe their diagnoses following Emergency Department (ED) discharge, and how this compares to electronic medical record (EMR) documentation.
Methods: We conducted a cohort study of patients discharged from three EDs. Patients completed questionnaires regarding their understanding of their diagnosis. Inclusion criteria: adult ED patients aged 18 and older seen within the last seven days. We independently compared patient-reported new diagnoses following discharge to EMR-documented diagnoses regarding diagnostic content (identical, insignificantly different, different, not enough detail) and the level of technical language in diagnostic description (technical, semi-technical, lay).
Results: The majority of participants (n=95 out of 137) reported receiving a diagnosis and stated the given diagnosis. Of those who reported their diagnosis, 66%, were females (n=62), the average age was 43 (SD 16), and a fourth (n=24) were Black and 66% (n=63) were white. The majority (84%) described either the same or an insignificantly different diagnosis. For 11% the patient-reported diagnosis differed from the one documented. More than half reported their diagnosis using semi-technical (34%) or technical language (26%), and over a third (40%) described their diagnosis in lay language.
Conclusions: Patient-reported diagnoses following ED discharge had moderate agreement with EMR-documented diagnoses. Findings suggest that patients might reproduce verbatim semi-technical or technical diagnoses they received from clinicians, but not fully understood what the diagnosis means for them.
Methods: We conducted a cohort study of patients discharged from three EDs. Patients completed questionnaires regarding their understanding of their diagnosis. Inclusion criteria: adult ED patients aged 18 and older seen within the last seven days. We independently compared patient-reported new diagnoses following discharge to EMR-documented diagnoses regarding diagnostic content (identical, insignificantly different, different, not enough detail) and the level of technical language in diagnostic description (technical, semi-technical, lay).
Results: The majority of participants (n=95 out of 137) reported receiving a diagnosis and stated the given diagnosis. Of those who reported their diagnosis, 66%, were females (n=62), the average age was 43 (SD 16), and a fourth (n=24) were Black and 66% (n=63) were white. The majority (84%) described either the same or an insignificantly different diagnosis. For 11% the patient-reported diagnosis differed from the one documented. More than half reported their diagnosis using semi-technical (34%) or technical language (26%), and over a third (40%) described their diagnosis in lay language.
Conclusions: Patient-reported diagnoses following ED discharge had moderate agreement with EMR-documented diagnoses. Findings suggest that patients might reproduce verbatim semi-technical or technical diagnoses they received from clinicians, but not fully understood what the diagnosis means for them.
| Original language | English |
|---|---|
| Pages (from-to) | 250-254 |
| Number of pages | 5 |
| Journal | Diagnosis (Berlin, Germany) |
| Volume | 9 |
| Issue number | 2 |
| Early online date | 16 Aug 2021 |
| DOIs | |
| Publication status | Published - 11 May 2022 |
| Externally published | Yes |
Keywords
- health communication
- patient-centred care
- patient-provider communication
- patient-report
- patient-centered care