26088770

PMC4861684

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.|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.|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.|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.

Stephen B. Thacker CDC Library collection
CDC Public Access

K12 HD001459/HD/NICHD NIH HHS/United States
KL2 RR024994/RR/NCRR NIH HHS/United States
KL2 TR000450/TR/NCATS NIH HHS/United States
R01 DK099534/DK/NIDDK NIH HHS/United States
U54 CK000162/CK/NCEZID CDC HHS/United States
UL1 RR024992/RR/NCRR NIH HHS/United States
UL1 TR000448/TR/NCATS NIH HHS/United States