One in three medical records contained at least one documentation shortcoming when health centres in Region Stockholm investigated patients with non-specific symptoms that could be signs of cancer. These are the findings of a new study from Karolinska Institutet published in BMJ Quality & Safety.
"We found that suspicions of cancer were not always documented, possibly because doctors wanted to avoid causing unnecessary anxiety when patients have direct access to their medical records online," says Elinor Nemlander , a general practitioner, researcher at the Department of Neurobiology, Care Sciences and Society at Karolinska Institutet, and national coordinator for early cancer detection. "This can make it more difficult for other doctors to understand, in retrospect, what diagnostic considerations were made."
Primary care plays an important role in monitoring patients
The study is based on a review of 1,116 medical records from 27 health centres in Region Stockholm in Sweden. The review was carried out by the doctors in charge of medical care at each health centre, who examined their unit's records using a structured review tool developed for quality improvement work. The patients were aged between 40 and 75 and had sought care for non-specific symptoms or findings which, in some cases, may be early signs of cancer, such as fatigue, weight loss or anaemia.
"These are very common symptoms that are usually not caused by cancer, but primary care plays an important role in monitoring these patients and initiating investigations when necessary," says Elinor Nemlander.
Using the review tool, doctors in charge at each health centre identified documentation-related factors that could hinder timely diagnosis. In total, 32 per cent of medical records contained at least one such issue. The most common concern, found in 21 per cent of the records, was that the reasoning behind possible diagnoses was unclear. The reviewing doctors noted that, while the records often described the actions taken, such as tests or referrals, they did not always explain why the decisions had been made.
Other issues included inadequate information gathering and failing to indicate in the medical records whether alternative diagnoses had been considered. The qualitative analyses revealed that some doctors may be reluctant to document suspicions of serious illness in medical records.
Hindering follow-up and assessment
The review also showed that doctors did not always reassess their judgements even when symptoms persisted or changed over time. Furthermore, fragmented care involving several different healthcare providers appeared to exacerbate these vulnerabilities, hindering follow-up and comprehensive assessment.
"We have not investigated whether these documentation-related issues have had any consequences for patients," says Elinor Nemlander. "However, our study highlights areas where documentation and follow-up can be improved to enhance patient safety in primary care."
The study was carried out in collaboration with Rita Fernholm and Caroline Kappelin at Karolinska Institutet as part of a regional quality improvement initiative in Region Stockholm. The research was not funded by any specific research grant, and no conflicts of interest were reported. The quality improvement initiative was funded by the Stockholm-Gotland Regional Cancer Centre.
Publication
"Documentation-related diagnostic safety concerns in primary care: a structured medical record review of 1116 patient records" , Rita Fernholm, Caroline Kappelin, Elinor Nemlander, BMJ Quality & Safety, online 17 September 2026, doi: 10.1136/bmjqs-2026-020701.
