Table 1.

Code book

Category	Description	Examples
Medication	Information related to medication(s) INCLUSION: Medication name, modifying medication attribute, confirming/documenting medication administration or intake EXCLUSION: None	“hold heparin” “give ceFAZolin” “Confirm if pt took meds”
ADT	Instructions or information related to admitting, transferring, or discharging patients INCLUSION: Terms such as “discharge,” “d/c,” “transfer,” “go back to floor,” or “leave ICU” EXCLUSION: Phrases referring to movement to or from scans, procedures, etc.	“Patient can be discharge home after PT/OT.” “Please give patient 1 time dose IV morphine 2 mg an hour prior to d/c or when doing PT, and then regular scheduled dose 8 mg dilaudid prior to leaving so comfortable when traveling. Thank you.” “Pt to be discharged with indwelling foley catheter” “The patient can go back to the floor once he meet the PACU discharge criteria”
Protocol	Information about a protocol to be followed INCLUSION: Phrases such as “as per XYZ protocol,” “follow XYZ procedure,” or “as per XYZ rule” EXCLUSION: None	“Initiate hypoglycemia protocol”
Documentation	Request for information or documentation, recording/changing information in the patient’s chart/EHR, or note instructions INCLUSION: Phrases referring to asking or informing about status post-procedure/therapy, requesting information from the patient, or requesting documentation or confirmation EXCLUSION: None	“Pls get records from xxx hospital” “pls confirm allergy” “pls document all episodes of hemostasis” “Confirm if pt took meds”
Transport	Introductions, clarification, and requests for patient transportation INCLUSION: Phrases referring to actual patient movement such as “pt to xray,” “pt to OR,” “pt can go off floor,” “pt to be discharged/meets d/c criteria” EXCLUSION: None	“Move pt to xray” “pt can go off the floor without tele”
Other clinical tasks	Permission or instructions for clinical procedures (not covered by L/T/D; Labs; Imaging; Medication; Transportation; Medical Device) INCLUSION: Phrases referring to activities such as dressing wounds, neuro checks, observations, or terms related to patient care activities such as “walking pt,” “cleaning pt,” etc. EXCLUSION: None	“Please clean forehead” “Pls walk patient” “Bladder scan” “pt to wear mask out of room “transfer 1 uprbc” “read chart” “no q1hr neuro checks”
Procedure	Information about procedures or instruction before a procedure INCLUSION: Phrases referring to blood transfusions, PT/OT evals, colonoscopies, surgeries, or therapies (OT, speech, etc.) EXCLUSION: None	“going for colonoscopy” “pt ok for PT/OT eval”
Lines/tubes/drains	Information about lines, tubes, or drains INCLUSION: Phrases such as “IV,” “IV Meds,” “NG tubes,” other tubes, “Foley,” “drains,” “drips,” “arterial/central/peripheral lines,” etc. EXCLUSION: None	“Ok to use central line” “D/C aterial” “Restart insulin drip” “NG tube to suction prior to starting CPAP”
Vitals	Information about patient vitals, instructions to skip taking vitals, or discontinue monitoring INCLUSION: Phrases referring to taking or skipping vital sign(s), including terms such as “weight,” “blood pressure,” or “height” EXCLUSION: None	“rectal temp” “daily wt” “pt can go off the floor without tele”
Devices	Information about medical devices, patient aides that are internal/external to the patient INCLUSION: Phrases referring to tele-monitoring, pacemakers, pumps, pulse-ox, walkers, or wheelchairs EXCLUSION: None	“LVAD speed changed from 9200 to 9400 RPM at the bedside by Dr XXXX at XXXX” “OK to go to dialysis, off tele” “Platform walker”
Labs	Clarification or instructions related to lab tests or imaging INCLUSION: Phrases such as “Xray,” “radiology,” “CT/MRI,” “Echo/EKG,” “BNP,” “CBC,” “blood draws,” “blood sugar (accu check),” or just labs EXCLUSION: None	“Please clean forehead and do accu check” “Move pt to xray”
Contact	Information about contacting or calling another provider, or asking for information from patient INCLUSION: Phrases such as “page,” “phone,” “call,” “contact,” or any other terms implying a communication from 1 person to another. Includes phone number, email, etc. EXCLUSION: Terms such as “as per Dr X said this…”	“page DR XXX XXX” “call MD”
Goal	Phrases referring to clinical goals for the patient INCLUSION: Explicitly states a numerical value or patient status to be achieved and/or includes the terms “goal,” “target,” etc. EXCLUSION: Reference to abnormal values (eg, hypertension)	“Goal oxygen sat >88%”
Diet	Phrases referring to patient food, fluid, diet INCLUSION: Phrases referring to “PO,” “NPO” or “Diet” or items surrounding food, fluid intake. Or, “diet related” activities such as an “order snacks” EXCLUSION: Information about lines/tubes/drains pertaining to diet but does not explicitly mention diet; code only as “Lines/Tubes/Drains.” Example: “NG tube to suction prior to starting CPAP”	“small sips of liquid” “PO challenge”
Education	Information about patient education or requesting patent education INCLUSION: Phrases such as “educate,” “inform patient,” “teach,” etc. in reference to the patient EXCLUSION: Terms above but directed toward clinical staff	“pls teach pt about diabetics”
Non-clinical task	Permission or instruction about issues outside of direct patient care INCLUSION: confirmation/ permission for tasks outside patient care EXCLUSION: None	“Spouse can meet pt outside visiting hours” “pt can use own shoes” “Ok to wear sweater”

Abbreviations: ADT, admission/discharge/transfer; BNP: Brain natriuretic peptide; CBC: Complete blood count; CPAP: Continuous positive airway pressure; CT: computed tomography; EHR: electronic health record; ICU: intensive care unit; LVAD: left ventricular assist device; MRI: Magnetic resonance imaging; NG: nasogastric; NPO: nil per os (nothing by mouth); OR: Operating Room; OT: Occupational therapy; PACU: Post-Anesthesia Care Unit; PO: per os (by mouth); PT: patient or physical theraphy; IV: Intravenous.