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Table 4 Sources of data contributing to “content elements of the note”

From: Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research

Content elements of the note Clinicians Nurse/ancillary Patients Admin.
Patient’s complaints
History of present illness (“HPI;” “subjective”)
Problem list
Past medical history
Medications list
Adverse drug reactions and allergies (distinguished from side effects of medications, which is included in prognosis and expectations)
Social and family history (includes the patient’s reaction to the diagnosis or health condition)     
Review of systems
Physical findings (pertinent positives and negatives; “objective;” vital signs)
Assessment (diagnosis; differential)
Plan of care (with goals and objectives)
Follow-up information (instructions for the patient; consults; orders; prescriptions; language and other learning barriers for patients)
Author information (name; title; discipline; date of encounter)
Patient identifiers
Prognosis and expectations (includes side effects of medications)     
Care and education delivered     
Information added by the patient     
Interdisciplinary information     
Infection alerts     
Patient priorities