Table 5 Sources of data contributing to “system supports for quality documentation”

Reliability and accessibility (works well when you need it; you can get into it; notes available when you need them)

Interoperability (integrated inpatient records, outpatient records, emergency department and pharmacy; information linked between facilities)

Structures input well (ease of writing; links to templates; time efficient; limits copying and pasting; easy to correct errors)

Structures output well (ease of viewing and reading; usable display; links to patient history including medical, surgical, medication, allergy and problem list information; links information between notes; links from diagnosis to occupational exposure; works well for security and patient privacy)

Time (time with patient; time to write notes)

Ancillary staff (available to help in clinic )

Relationship with patient (good relationship facilitates good note)

Workstations (place to see patients and write notes that is convenient)

Can correct errors

Patient computer (for patient to answer questions)

Education and training (sufficient training on how to write notes in the EHR and use templates or formats)