Table 4

Sources of data contributing to “content elements of the note”
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

Hanson et al.

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

Open Data