Table 2.

Quality of Diagnostic “Assessment of the Assessment” Elements in the Chart: Results of Review of 100 Charts

Domain and individual items	Mean (SD)
Diagnostic assessment	2.0 (0.92)
a. Chief complaint	2.4 (1.87)
b. Differential diagnosis	2.1 (1.66)
c. Psychosocial information	0.6 (1.39)
d. Possible etiologies	3.1 (1.46)
e. Degree of certainty	1.9 (1.64)
Follow-up plan	1.7 (0.83)
a. Mentions diagnostic tests	2.5 (2.06)
b. Contingencies	2.3 (1.83)
c. Time frames	0.9 (1.77)
d. Rationale	1.0 (1.73)
Situational awareness/safety nets	1.7 (1.09)
a. Red Flags:	2.0 (1.36)
b. Don’t miss diagnoses	2.7 (1.75)
c. Pitfalls	0.5 (1.44)
Other diagnostic assessment elements	4.7 (1.20)
a. Quality of diagnosis/differential diagnosis	3.6 (1.32)
b. Adequate tests	4.7 (1.26)
c. Avoids over-testing	5.5 (0.92)
d. Succinctness	4.9 (1.07)
e. Clinician readability	5.7 (0.66)
f. Patient readability	2.9 (0.86)
g. Avoids legal liability pejorative red flags	6.0 (0.00)