Low correlation between self-report and medical record documentation of urinary tract infection symptoms.

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:

24 Apr 2018 10:11

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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