We asked clinicians, nurses/ancillary staff, administrators and patients/caregivers to describe quality in clinical documentation. Three organizing themes emerged: 1) characteristics of quality in clinical note—11 key characteristics were described; 2) content elements of clinical notes—20 key elements were described; 3) system support factors for writing quality clinical notes—11 key factors were described.
The organizing theme regarding the characteristics of a note provides a collective description of quality on which the four stakeholder groups substantially agreed. The theme delineating desirable content elements within a note provides a list that could be used to measure a note’s comprehensiveness. While the four groups agreed on many important content elements (patient complaints, symptoms, problems, history, medications, assessment and plan of care), they included or emphasized some elements very differently. Nurses and patients emphasized the importance of detailed, clear, practical information about needed follow-up care, as well as information provided by the patient, such as patient entries in the note or other documentation about patient priorities and patients’ explanations of their problems. Nurses also emphasized the importance of interdisciplinary contributions to a note, to assist with continuity of story. Administrators emphasized the importance of easy translation of information in the notes to codes for medical billing purposes. The third organizing theme we identified relates to system factors that facilitate or inhibit quality clinical documentation. Issues such as data entry, clinical workflow, system interoperability, access, reliability and data output all impact the end-product in terms of quality documentation.
The inclusion of patients in our study calls to mind the work of Delbanco and colleagues in the OpenNotes project
[30, 31]. Most of the patients and caregivers in our study had not seen outpatient notes about their care, which is the reason we created a modified interview guide to elicit their perspectives. They were, nevertheless, able to explain what information they wanted to have in a note about them, such as their priorities for their care, and how a note could help them coordinate their own care or explain their healthcare needs to other family members. Perhaps as patients have opportunities to read their notes, as in the OpenNotes project, more conversations will emerge about what quality means to those about whom the notes are written.
The grounded theory that emerges is that our stakeholder groups agree on most characteristics of quality in a note. A high-quality outpatient clinical note is concise, explanatory, clear, relevant, prioritized, readable, organized, current and accurate. A quality note contains sufficient information for the reader to understand its rationale and tells a coherent and continuous story. Since individuals define quality in terms of content, as it relates to their role when using the note, it follows that quality content as defined by clinicians differs from that as defined by nurses, administrators and patients. Therefore, we plan to devise a quality rating instrument that encompasses multiple perspectives.
The research participants from the clinician and nurse stakeholder groups also noted that the health care records system impacts quality documentation according to reliability, accessibility, interoperability and the structure of data input and output, and that the clinical system also makes the production of quality notes more or less likely. System issues related to time, staffing, the support of clinician/patient relationships, convenient workstations, patient data entry, and education/training may also influence quality in clinical documentation. When we began this study, we tried to focus the discussion on quality of notes apart from reference to whether the record system was paper-based or electronic. The clinical participants, however, spoke from the context of their work and commented extensively about the influence of the electronic record system on the quality of notes they wrote and read. In accordance with qualitative research methods, we added 2 questions about this to the focus group guide as the study progressed (Appendix 1) and we reported themes about influence of the EHR on quality as they emerged from the analysis. Nevertheless, there are definite limitations to the insight that this study can add to the complex question of how factors related to EHR use may affect the quality of clinical documentation. This question warrants study in future research.
Our results add additional characteristics and elements of quality in clinical documentation to the existing literature. For example, the traditional structural elements in a SOAP note appear on our list of content elements as well. The clinicians in our study likely acquired this standard terminology during their medical education. Our characteristics also confirm those noted by Stetson et al. that describe quality documentation in the inpatient setting. The themes in the current study, however, describe additional aspects of quality documentation that arise in the outpatient setting, such as integration of insights and care across disciplines and incorporation of patients’ priorities in ongoing treatment plans and care. These may, of course, also be important in the inpatient setting; and they might also be identified by our study design when applied to clinical documentation for inpatients. A key additional finding from our stakeholders is that quality notes are also “explanatory” and provide “continuity of story”. “Continuity of story” relates to “narrative expressivity” as identified by Rosenbloom and colleagues in their work with clinicians
[6, 32]. In our study the concept arose across stakeholder groups and included connecting different aspects of the patient’s story and care, which seems to go beyond the “narrative expressivity” and “flexibility” described in Rosenbloom’s work. This continuity of story highlights that a single patient encounter occurs in a clinical context, often as one of a series of encounters. Often different disciplines and multiple healthcare professionals are involved with varying degrees as part of a patients’ longitudinal story. A single clinical note represents one clinical encounter, a ‘chapter’ in an evolving health care story in the life of the patient. The best notes, according to our groups, make clear the connections between different chapters and thereby enrich the patient’s story.
Our results also provide insight about the information that various stakeholders seek when defining quality in clinical documentation. Administrators, patients and nurses seek different information to fulfill their roles or implement the care recommendations they receive. The clinical note, therefore, contains interdisciplinary practical context that cannot be ignored in a comprehensive definition or evaluation of quality. It may be that the published literature to date has emphasized clinicians’ needs, with less focus on how the clinical note affects other healthcare providers and patients.
Our data were collected within a single healthcare system, which may be a limitation of the study. While the system is large and the sample diverse, and we believe that the literature shows the system to be comparable to other large managed care organizations
[23, 24], future research should replicate our study in other systems. Another limitation applies particularly to the insights put forth about how systems issues may affect the quality of clinical documentation. Since the focus of the study is quality of notes, not the systems within which notes are written, the scope of our findings for this theme is likely limited. A more thorough treatment of the impact of systems on note quality would require a focused study on this question in settings that use a variety of documentation systems.
Our research-based definition of quality in clinical documentation describes quality in a clinical note from the perspectives of those who most commonly use the note for clinical, nursing or administrative purposes and the patients who are the subject of the note. The inclusion of the voice of those who use these notes, and the patients about whom these notes are written, represents a novel contribution to the understanding of “quality” in this context. We suggest that comprehensive study of quality of clinical documentation should incorporate the perspectives of these various stakeholder groups, and that achieving quality outpatient clinical documentation requires addressing the needs described by those who use clinical notes to plan, implement and pursue care, as well as by those who write the notes and use them to document what happens in the clinical encounter.