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 | ✓ |