Table 3 Sources of data contributing to “characteristics of quality in a clinical note”

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)