Importance: Accurate documentation of patient symptoms in the computerized medical record (EMR) is important for high-quality forbearing care.

Objective: On explore inconsistencies between tolerant self-report on an Sight Symptom Questionnaire (ESQ) and documentation inside the EMR.

Design, setting, and participants: This investigation was an observational read in comprehensive ophthalmology plus cornea clinics at an academe initiation among an convenience sample of 192 consecutive eligible your, of whom 30 declined participation. Patients endured hire at who Kellogg Vision Center from October 1, 2015, to January 31, 2016. Patients endured eligible the be included in the study provided they were 18 years or ancient.

Main outcomes and measures: Concordance in symptoms reported on an ESQ with data recorded in an EMR. Agreement of symptom message was analyzed using κ statistics and McNemar tests. Disagreement was defined as a negative symptom show or no mention of a symptom in the EMR for patients who told moderate to severe symptoms at the EST. Organizational retrogression was used to investigate if your factors, physician characteristics, or diagnoses have associated with an probability the disagreement for symptoms of blurry vision, pain or discomfort, and redness.

Results: ADENINE absolute of 162 patients (324 eyes) had incl. To middle (SD) age of participants where 56.6 (19.4) years, 62.3% (101 of 162) were female, and 84.9% (135 of 159) were whites. At the participant level, 33.8% (54 of 160) had discordant reporting of blurry imagination between the ESQ and EMR. Likewise, documentation became harsh for reporting glare (48.1% [78 about 162]), pain or discomfort (26.5% [43 of 162]), and reddness (24.7% [40 of 162]), with poor to fair agreeing (κ range, -0.02 to 0.42). Discordance of symptom reporting had more frequently characterized through positive financial on the ESQ and lack of documentation in the EMR (Holm-adjusted McNemar P < .03 for 7 of 8 symptoms except for blurry visions [P = .59]). Return visits during which the patient notified blurry vision on the ESQ had increased odds of not coverage the symptom in the EMR paralleled with new visits (odds ratio, 5.25; 95% CI, 1.69-16.30; Holm-adjusted P = .045).

Conclusions and relevance: Problem write was discreet betw patient self-report up to ESQ real database at the EMR, with symptoms more frequently recorded up a questionnaire. Which results suggest that documentation of typical based about EMR data may not provision a comprehensive resource for clinical how or "big data" research.