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. Author manuscript; available in PMC: 2019 Jan 1.
Published in final edited form as: J Biomed Inform. 2017 Nov 21;77:34–49. doi: 10.1016/j.jbi.2017.11.011

Table 1.

The most frequently used note types for clinical notes (top 5) and diagnostic reports (top 3) and the corresponding brief descriptions and number of papers in the included publications.

Note Type Brief Description No. of Papers
Clinical notes Discharge summaries A document that describes the outcome of a patient’s hospitalization, disposition, and provisions for follow-up care. 26
Progress notes A document that describes a patient’s clinical status or achievements during the course of a hospitalization or over the course of outpatient care. 15
Admission notes A document that describes a patient’s status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient’s care. 9
Operative notes A document that describes the details of a surgery. 5
Primary care notes A document that describes the details of an outpatient during a primary care. 3
Diagnostic reports Radiology reports Results of radiological scans and X-ray images of various parts of the patient’s body and specific organs. 43
Pathology reports Results of pathological examinations of tissue samples and tissues of organs removed during surgical procedures. 22
Colonoscopy reports Results of a colonoscopy. 4