Table 1.

Description of the clinical notes categories.

Source	Note type	Description
Specialist care	Discharge summaries/outpatient summaries	These documents include formal reports written after hospital admissions or outpatient encounters. They typically contain diagnoses, treatments, key clinical findings, and follow-up plans.
	Progress notes	Clinical notes documenting patient assessments, follow-up, treatment, and changes in health status during ongoing care.
	Letters to Patient	Communication addressed to patients, such as admission letters, appointment notifications, rescheduled or follow-up appointments, and waiting list updates.
	Admission notes	Initial clinical assessments written when a patient is admitted to the hospital, documenting presenting issues, early findings, and initial management plans.
	Nursing notes	Documentation created by nursing staff, including day, evening, and night reports; outpatient nursing notes; specialist nurse reports; and nursing admission or transfer notes. These notes describe observations, care activities, and clinical changes.
	Lab reports	Recorded laboratory results and related diagnostic information.
	Other clinical documents	Less frequent documents including diagnostic findings from imaging, medication-related information, administrative communications, and exchanges of clinical information between healthcare providers.
Municipal health and social care	Municipal notes	Documentation generated by municipal healthcare services, such as home care and nursing services.
GP	Out-of-hours primary care service	Documentation describes assessments, interventions, and clinical decisions made during urgent patient encounters outside regular GP hours.
	General practitioner notes	Notes written by the patient’s GP, representing ongoing primary care follow-up and medical management.