Table 2.

Themes and codes

Characteristics of quality in a clinical note [Main organizing theme]
a	Conciseness (focused; brief; not redundant)
b	Sufficiency of information (enough information for diagnosis, treatment, coding; pertinent details present; complete for its purpose)
c	Explanatory (explains clinician thought process; gives reasons for diagnosis and plan)
d	Clarity (clear; understandable to patients, to subsequent providers, and to other users)
e	Relevance (only relevant information; no extraneous information)
f	Prioritized
g	Readability (readable font; correct spelling; no abbreviations or only unambiguous abbreviations; readable output from EHR; legible handwriting; understandable syntax)
h	Organization (well-organized; logically grouped; chronological; important parts highlighted; can find the information you need easily)
i	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; synthesizes information; coordinates information from different sources)
j	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)
k	Ease of translation into codes (diagnostic; procedural; other)
Content elements of the note
a	Patient’s complaints
b	History of the present illness (“HPI”; “subjective”)
c	Problem list
d	Past medical history
e	Medications list
f	Adverse drug reactions and allergies (distinguished from side effects of medications, which is included in prognosis and expectations)
g	Social and family history (includes the patient’s reaction to the diagnosis or health condition)
h	Review of systems
i	Physical findings (pertinent positives and negatives; “objective;” vital signs)
j	Assessment (diagnosis; differential)
k	Plan of care (with goals and objectives)
l	Follow-up information (instructions for the patient; consults; orders; prescriptions; language and other learning barriers for patients)
m	Author information (name; title; discipline; date of the encounter)
n	Patient identifiers
o	Prognosis and expectations (includes side effects of medications)
p	Care and education delivered
q	Information added by the patient
r	Interdisciplinary information
s	Infection alerts
t	Patient priorities
System supports for quality documentation
a	Reliability and accessibility (works when you need it; you can get into it; notes available when you need them)
b	Interoperability (integrated inpatient records, outpatient records, emergency department and pharmacy; information linked between facilities)
c	Structures input well (ease of writing; links to templates; time efficient; limits copying and pasting; easy to correct errors)
d	Structures output well (for ease of viewing and reading; useable display; links to patient’s history—medical, surgical, medications, allergies, problem list; links information between different notes; you can find needed information about a patient; links from diagnosis to occupational exposure; works well for security and patient privacy)
e	Time (time with patient; time to write notes)
f	Ancillary staff (available to help in clinic)
g	Relationship with patient (good relationship facilitates good note)
h	Workstations (place to see patients and write notes is convenient)
i	Can correct errors
g	Patient computer (for patient to answer questions)
k	Education and training (sufficient training on how to write notes in the EHR and use templates or formats)