From: Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research
Characteristics | Clinicians | Nurse/ancillary | Patients | Administrators |
---|---|---|---|---|
Conciseness (focused; brief; not redundant) | ✓ | ✓ | ✓ | |
Sufficiency of information (enough information for diagnosis, treatment, coding; pertinent details present;, complete for its purpose) | ✓ | ✓ | ✓ | ✓ |
Explanatory (explains clinician thought process; gives reasons for diagnosis, plan) | ✓ | ✓ | ✓ | ✓ |
Clarity (clear or unclear; understandable to patients, to subsequent providers, to other users) | ✓ | ✓ | ✓ | ✓ |
Relevance (only relevant information; no extraneous information) | ✓ | ✓ | ||
Prioritized | ✓ | |||
Readability (readable font; correct spelling; no abbreviations or only unambiguous abbreviations; readable output from EHR; legible handwriting; understandable syntax) | ✓ | ✓ | ✓ | ✓ |
Organization (well-organized; logically grouped; chronological; important parts highlighted; can find the information you need easily) | ✓ | ✓ | ✓ | ✓ |
Continuity of story (tells a story; written in free text with a flow that makes sense; shows continuity from referral to note and from one provider to another; internally and externally consistent; facilitates follow-up with the information provided; synthesis) | ✓ | ✓ | ✓ | ✓ |
Current and accurate (has current information; up-to-date; correct; from a patient’s perspective, accuracy includes honesty and whether the note includes what the patient said) | ✓ | ✓ | ✓ | ✓ |
Ease of translation into codes (diagnostic; procedural; other) | ✓ | ✓ |