. 2005 Jul-Aug;12(4):438–447. doi: 10.1197/jamia.M1777

Table 2.

Example Field Notes from Site 1

Time	Actors and Content
2:10pm	Checks into CPRS. Dr. X: Can you walk at all? Pt: No Clicks to progress note before CRs there, clicks to cover sheet [still processing CRs] Left side has been hurting. Nursing home for 20 days. Dr: Are you coming up on your time to go home? Pt: I don't know. Dr looking through note. Starts new progress note: “see addendum to [date] note” Pt: Swelling on left hand. See how much larger the left is than the right? Dr. X does not see because looking at the computer. Dr. X? Dr. X looks and says: Yes, that is quite a bit more swollen. Turns back to computer.

Time

Actors and Content

2:10pm

Checks into CPRS. Dr. X: Can you walk at all? Pt: No Clicks to progress note before CRs there, clicks to cover sheet [still processing CRs] Left side has been hurting. Nursing home for 20 days. Dr: Are you coming up on your time to go home? Pt: I don't know. Dr looking through note. Starts new progress note: “see addendum to [date] note” Pt: Swelling on left hand. See how much larger the left is than the right? Dr. X does not see because looking at the computer. Dr. X? Dr. X looks and says: Yes, that is quite a bit more swollen. Turns back to computer.

CPRS = Computerized Patient Record System; CRs = clinical reminders.