Table 3.

Sources of data contributing to “characteristics of quality in a clinical note”

Characteristics	Clinicians	Nurse/ancillary	Patients	Administrators
Conciseness(focused; brief; not redundant)		✓	✓	✓
Sufficiency of information(enough information for diagnosis, treatment, coding; pertinent details present;, complete for its purpose)	✓	✓	✓	✓
Explanatory(explains clinician thought process; gives reasons for diagnosis, plan)	✓	✓	✓	✓
Clarity(clear or unclear; understandable to patients, to subsequent providers, to other users)	✓	✓	✓	✓
Relevance(only relevant information; no extraneous information)	✓	✓
Prioritized			✓
Readability(readable font; correct spelling; no abbreviations or only unambiguous abbreviations; readable output from EHR; legible handwriting; understandable syntax)	✓	✓	✓	✓
Organization(well-organized; logically grouped; chronological; important parts highlighted; can find the information you need easily)	✓	✓	✓	✓
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; synthesis)	✓	✓	✓	✓
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)	✓	✓	✓	✓
Ease of translation into codes(diagnostic; procedural; other)	✓			✓