Objective: To describe documentation of CINV from the EHR and to map this concept through UMLS.
Methods: We annotated EHRs to identify domains where CINV was reported in pediatric cancer patients and report agreement by provider type and ICD-10 codes. We mapped the terms through UMLS to identify gaps in terminologies and develop a post-coordination expression.
Results: Thirty EHR encounters receiving chemotherapy were reviewed. CINV was assessed in 73% of prescriber documentation and 100% of RN documentation; CINV was reported in 26% of provider documentation and 33% of RN documentation. There was poor agreement between ICD-10 codes and documentation of CINV.
Conclusion: Documentation of CINV in the EHR is frequently incomplete and discordant by provider type. Post-coordination expression may be a useful approach.
Learning Objective: 1. To describe the documentation of chemotherapy induced nausea vomiting and the gaps in the currently-available definitions in common terminologies.
2. To describe how electronic health records might better support provider documentation of CINV by utilitizing informatics-based approaches.
Melissa Beauchemin (Presenter)
Rebecca Schnall, Columbia University
Chunhua Weng, Columbia University