Echaiz, Jose F; Cass, Candice; Henderson, Jeffrey P; Babcock, Hilary M; Marschall, Jonas (2015). Low correlation between self-report and medical record documentation of urinary tract infection symptoms. American journal of infection control, 43(9), pp. 983-986. Elsevier 10.1016/j.ajic.2015.04.208
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BACKGROUND
Correlations between symptom documentation in medical records and patient self-report (SR) vary depending on the condition studied. Patient symptoms are particularly important in urinary tract infection (UTI) diagnosis, and this correlation for UTI symptoms is currently unknown.
METHODS
This is a cross-sectional survey study in hospitalized patients with Escherichia coli bacteriuria. Patients were interviewed within 24 hours of diagnosis for the SR of UTI symptoms. We reviewed medical records for UTI symptoms documented by admitting or treating inpatient physicians (IPs), nurses (RNs), and emergency physicians (EPs). The level of agreement between groups was assessed using Cohen κ coefficient.
RESULTS
Out of 43 patients, 34 (79%) self-reported at least 1 of 6 primary symptoms. The most common self-reported symptoms were urinary frequency (53.5%); retention (41.9%); flank pain, suprapubic pain, and fatigue (37.2% each); and dysuria (30.2%). Correlation between SR and medical record documentation was slight to fair (κ, 0.06-0.4 between SR and IPs and 0.09-0.5 between SR and EDs). Positive agreement was highest for dysuria and frequency.
CONCLUSION
Correlation between self-reported UTI symptoms and health care providers' documentation was low to fair. Because medical records are a vital source of information for clinicians and researchers and symptom assessment and documentation are vital in distinguishing UTI from asymptomatic bacteriuria, efforts must be made to improve documentation.
Item Type: |
Journal Article (Original Article) |
|---|---|
Division/Institute: |
04 Faculty of Medicine > Department of Haematology, Oncology, Infectious Diseases, Laboratory Medicine and Hospital Pharmacy (DOLS) > Clinic of Infectiology |
UniBE Contributor: |
Marschall, Jonas |
Subjects: |
600 Technology > 610 Medicine & health |
ISSN: |
0196-6553 |
Publisher: |
Elsevier |
Language: |
English |
Submitter: |
Annelies Luginbühl |
Date Deposited: |
12 May 2016 10:32 |
Last Modified: |
05 Dec 2022 14:56 |
Publisher DOI: |
10.1016/j.ajic.2015.04.208 |
PubMed ID: |
26088770 |
Uncontrolled Keywords: |
Correlation; Medical record; Self-report; Symptom; Urinary tract infection |
BORIS DOI: |
10.7892/boris.82242 |
URI: |
https://boris.unibe.ch/id/eprint/82242 |
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