Does the medical record cover the symptoms experienced by cancer patients receiving palliative care? A comparison of the record and patient self-rating

The aim of this study was to investigate the extent to which the symptoms e xperienced by advanced cancer patients were covered by the medical records. Fifty-eight patients participated in the study. On the day of first encoun ter with our palliative care department, a medical history was taken, and o n this or the following day, the patients completed the EORTC Quality of Li fe Questionnaire (EORTC QLQ-C30), Edmonton Symptom Assessment System (ESAS) , and Hospital Anxiety and Depression Scale (HADS). The symptomatology repo rted in the patient-completed questionnaires was compared with the symptoma tology mentioned by the physician in the medical record. The analysis revea led good concordance concerning pain, but most other symptoms or problems w ere reported much more often by patients than by their doctors. Reasons for these discrepancies are discussed. It is suggested that the doctor's knowl edge of the patient's symptomatology might gain from more systematic screen ing and transfer of information from patient self-assessment questionnaires to the medical records. J Pain Symptom Manage 2001;21:189-196. (C) U.S. Ca ncer Pain Relief Committee, 2001.