Table 3

Sources of data contributing to “characteristics of quality in a clinical note”
Characteristics Clinicians Nurse/ancillary Patients Administrators
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)
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)

Hanson et al.

Hanson et al. BMC Health Services Research 2012 12:407   doi:10.1186/1472-6963-12-407

Open Data