Parents frequently voice concerns and treatment preferences during consultations about elective surgery for children, but many of these perspectives do not appear in the medical record. A study in BMC Medical Informatics and Decision Making compared recorded conversations with the corresponding clinical notes from outpatient surgical visits at a US academic medical centre. Nearly half of the encounters included at least one parental concern or preference, while fewer than half of the individual statements were documented. When clinicians did record these views, the written account usually matched the discussion, indicating that the main gap involved whether family perspectives were captured rather than whether they were represented accurately.
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Comparing Spoken Decisions with Clinical Records
The assessment covered 109 outpatient encounters involving 16 clinicians and parents or guardians of children being evaluated for elective surgery. Most visits concerned tonsillectomy, with smaller numbers involving hernia repair or circumcision. The children ranged from infancy to 17 years of age. Encounters took place across paediatric otolaryngology, urology and general surgery clinics over a three-year enrolment period.
Each consultation was audio-recorded and transcribed, then compared with the corresponding electronic health record entry. The comparison focused on two elements of shared decision-making: parental concerns and parental preferences. Concerns included explicit expressions of worry, fear or apprehension, commonly relating to symptoms, surgery or anaesthesia. Preferences covered stated priorities, goals, values and trade-offs, including choices about treatment, timing and practical arrangements.
The content was examined at both visit and individual-statement level. The visit-level assessment identified whether a consultation contained at least one concern or preference. The individual-statement assessment examined whether every distinct concern or preference expressed verbally had a corresponding entry in the record. This distinction separated the presence of family input from the completeness with which it was documented. Default wording from electronic templates was excluded because its inclusion did not show whether a clinician had intentionally captured a family perspective. Parents and clinicians also completed demographic questionnaires, but participant characteristics were not used to compare documentation patterns.
Documentation Captures Fewer Than Half of Family Views
Parents expressed concerns in 46 of the 109 consultations and preferences in 49. Across those visits, the conversations contained 74 distinct concerns and 62 distinct preferences. Only 34 concerns and 28 preferences had corresponding documentation, leaving more than half of each type absent from the medical record.
Most parental concerns related to the child’s symptoms. These included worries about breathing, sleep and daytime effects. Smaller groups concerned surgical risk, treatment decisions, anaesthesia and practical or other issues. Preferences were more concentrated: most involved the management decision itself, while others addressed surgical planning, logistics or the timing of treatment.
Accuracy was high when family views were entered in the record. Of the 34 documented concerns, 33 matched what had been expressed during the consultation. All 28 documented preferences were concordant with the spoken discussion. One concern was recorded inconsistently: a parent worried that illness-related absence was causing a child to fall behind at school, while the record stated that the child was doing well at school.
The findings therefore show a consistent difference between spoken shared decision-making and its written trace. Family perspectives were commonly part of the consultation, yet the record often contained no corresponding account. The principal pattern was omission rather than widespread distortion of what parents had said.
Clearer Records Could Support Continuity and Transparency
Clinical notes can convey what matters most to families, including treatment priorities, fears, practical barriers and values influencing a decision. Recording these points may help other members of a multidisciplinary team understand the context behind a chosen plan. It may also strengthen continuity when care passes between clinicians or services and make family involvement more visible in the record.
Sparse documentation can create the appearance that shared decision-making did not occur even when parents participated actively during the consultation. This gap may become more relevant as documentation practices change, including through the use of ambient artificial intelligence scribes. Attention to how family concerns and preferences are captured could help standardise records and provide a basis for assessing patient- and family-centred care.
Several limits constrain the findings. Most encounters came from paediatric otolaryngology at one institution, so the results may reflect local workflows, individual documentation styles or subspecialty practices. Identifying concerns and preferences in conversation also involves judgement, despite double-coding of part of the material and consensus between coders. Templated language was excluded, although clinicians may sometimes use it deliberately. Differences by patient or encounter characteristics were not examined, nor was who initiated the discussion or how consistently children themselves participated in decisions. Broader evaluation across institutions, disciplines and clinical contexts is therefore needed.
Parental concerns and preferences are often voiced during elective paediatric surgery consultations but are not consistently carried into the clinical record. The mismatch is driven mainly by missing documentation, because recorded views usually correspond closely with the conversation. More deliberate capture of family values, fears and treatment priorities could improve transparency, communication and continuity across care teams. At the same time, the single-institution setting and concentration of visits in one surgical specialty limit how widely the findings can be applied. Documentation practices require further assessment across different clinicians, services and care environments.
Source: BMC Medical Informatics & Decision Making
Image Credit: iStock
References:
Kelly A, Mitchell D, Links AR et al. (2026) Does clinical documentation reflect how parents and clinicians share decisions about surgery? BMC Med Inform Decis Mak. https://doi.org/10.1186/s12911-026-03566-2
