Content Analysis of Serious Illness Conversation Documentation: Structured vs. Free-Text Information

Context: Clear, accessible, and thorough documentation of serious illness conversations helps ensure that critical information patients share with clinicians is reflected in their future care. Objectives: We sought to characterize and compare serious illness conversations recorded in two different ways in the electronic health record to better understand patterns of serious illness conversation documentation. Methods: We performed content analysis of serious illness conversations documented in the electronic health record, whether documented via structured tab or free-text clinical notes, for patients (n = 150) with advanced cancer who started a treatment associated with a poor prognosis between October 2020 and June 2022. A multidisciplinary team iteratively developed a codebook to classify serious illness conversation content (e.g., goals/hopes) on a preliminary sample (n = 30), and two researchers performed mixed deductive-inductive coding on the remaining data (n = 120). We reviewed documentation from 34 patients with serious illness conversations documentation in the structured tab only, 43 with documentation in only free-text clinical notes, and 44 with documentation of both types. We then compared content between documentation types. Results: Information documented more frequently in structured tabs included fears/worries and illness understanding; clinical notes more often included treatment preferences, deliberations surrounding advance directives, function, and trade-offs. Qualitative insights highlight a range of length and detail across documentation types, and suggest notable authorship by palliative and social work clinicians. Conclusion: How serious illness conversations are documented in the electronic health record may impact the content captured. Future quality improvement efforts should seek to consolidate documentation sources to improve care and information retention.