Table 2 Themes and codes

a

Conciseness (focused; brief; not redundant)

b

Sufficiency of information (enough information for diagnosis, treatment, coding; pertinent details present; complete for its purpose)

c

Explanatory (explains clinician thought process; gives reasons for diagnosis and plan)

d

Clarity (clear; understandable to patients, to subsequent providers, and to other users)

e

Relevance (only relevant information; no extraneous information)

f

Prioritized

g

Readability (readable font; correct spelling; no abbreviations or only unambiguous abbreviations; readable output from EHR; legible handwriting; understandable syntax)

h

Organization (well-organized; logically grouped; chronological; important parts highlighted; can find the information you need easily)

i

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; synthesizes information; coordinates information from different sources)

j

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)

k

Ease of translation into codes (diagnostic; procedural; other)

Content elements of the note

a

Patient’s complaints

b

History of the present illness (“HPI”; “subjective”)

c

Problem list

d

Past medical history

e

Medications list

f

Adverse drug reactions and allergies (distinguished from side effects of medications, which is included in prognosis and expectations)

g

Social and family history (includes the patient’s reaction to the diagnosis or health condition)

h

Review of systems

i

Physical findings (pertinent positives and negatives; “objective;” vital signs)

j

Assessment (diagnosis; differential)

k

Plan of care (with goals and objectives)

l

Follow-up information (instructions for the patient; consults; orders; prescriptions; language and other learning barriers for patients)

m

Author information (name; title; discipline; date of the encounter)

n

Patient identifiers

o

Prognosis and expectations (includes side effects of medications)

p

Care and education delivered

q

Information added by the patient

r

Interdisciplinary information

s

Infection alerts

t

Patient priorities

System supports for quality documentation

a

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

b

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

c

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

d

Structures output well (for ease of viewing and reading; useable display; links to patient’s history—medical, surgical, medications, allergies, problem list; links information between different notes; you can find needed information about a patient; links from diagnosis to occupational exposure; works well for security and patient privacy)

e

Time (time with patient; time to write notes)

f

Ancillary staff (available to help in clinic)

g

Relationship with patient (good relationship facilitates good note)

h

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

i

Can correct errors

g

Patient computer (for patient to answer questions)

k

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