ArticleJournal of the American Medical Informatics Association : JAMIA2025
Comparing patient-reported symptoms and structured clinician documentation in electronic health records.
Article in Journal of the American Medical Informatics Association : JAMIA, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 3 papers.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
3 citing papers in PubMed.
- Characterization and validation of EHR computable phenotypes for Long COVID using patient-reported symptoms: insights from the nationwide RECOVER program.Journal of the American Medical Informatics Association : JAMIA · 2026Article
- Concordance Between Patient-Reported and Clinically Documented Symptoms in Acute Myeloid Leukemia.Oncology nursing forum · 2026Article
- Symptom burden in cancer survivorship: insights from a survivorship program's patient-reported outcomes database.Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation · 2026Article
Corrections and comments
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Authors and funding
5 authors.
Funding
Abstract
objectivesReal-world data (RWD) analyses primarily rely on structured clinical documentation collected through routine clinical care or driven by medical billing requirements. Patient-reported outcome measures (PROMs), integrated into electronic health records (EHRs), are an additional data source that could offer valuable insights into a patient's perspective and contribute to a more comprehensive understanding of health outcomes in RWD studies. This study aims to characterize agreement between PROMs symptoms and structured clinical documentation of these symptoms by clinicians in EHRs. MATERIALS AND
methodsA cross-sectional study of 913 244 adult primary care annual physical visits between January 1, 2019 and December 31, 2023. We compared differences in prevalence and agreement of patient-reported symptoms (PRS) and structured clinician documentation (CD) across 15 respiratory, gastrointestinal, cardiometabolic, and neuropsychiatric symptoms.
resultsPatient-reported symptom prevalence were significantly higher compared to CD across most symptoms including joint pain (33% PRS vs 12%), headaches (17% PRS vs 8.8% CD), and sleep disturbance (24% PRS vs 10% CD). Clinicians documented anxiety (11% PRS vs 23% CD) and depression (6.6% PRS vs 15.4% CD) symptoms using structured code at higher rates than patients reported them. Agreement between symptom self-report and clinician-documented structured codes was low to moderate (κ: 0.06-0.39). DISCUSSION: Primary care patients self-report symptoms up to ten times more frequently than clinicians document them with structured codes in the EHR.
conclusionThis work demonstrates the value and feasibility of incorporating PRSs in RWD studies to reduce misclassification and more holistically capture a patient's health.
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Registered trials
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