A tool called QNOTE was found effective in evaluating the quality of clinical notes, according to a study from the Maryland-based Uniformed Services University of the Health Sciences.
Quality clinical notes are key to improving patient care, the authors write in an article at the Journal of the American Medical Informatics Association. The point to three key functions the notes serve:
- They document the clinician's information collection, problem assessment and plan for the patient;
- They create a complete and accurate record that can be used by other clinicians to care for the patient;
- They provide substantiation for what was done for legal reasons and reimbursement.
Efforts to assess the quality of clinical notes has become easier with widespread adoption of electronic health records (EHRs)--for one thing, the data is typed rather than handwritten. However, QNOTE performed equally wall on handwritten notes, the authors write.
QNOTE creates a quality score based on the sum of 12 elements: chief complaint, history of present illness, problem list, past medical history, medications, adverse drug reactions, social and family history, review of systems, physical findings, assessment, plan of care, and follow-up information. Each element is assessed using seven criteria: whether each is clear, complete, concise, current, organized, prioritized and contains sufficient information.
The study involved 300 clinical notes from primary care clinic patients with type 2 diabetes mellitus--a condition chosen because patients often have multiple conditions, making quality notes more important, according to the authors.
Eight general internists and eight family medicine practitioners were equally divided into four groups assessing notes comparing those using the QNOTE instrument and a global subjective assessment that graded notes as a whole. In this case, the authors found the sum of the parts led to greater quality than assessing the whole.
"It is an important advance because it provides a valid instrument for determining the quality of a clinical encounter, as documented by the clinician's note. Further, it provides a way for clinicians to assess their electronic notes and to use that knowledge to improve their documentation," they wrote.
Numerous healthcare organizations have launched clinical documentation improvement initiatives as part of their move to ICD-10, including Baptist Health South Florida, which has dubbed the effort "CDI: Miami."
While EHR data can be used to flag problems such as diabetes and potential suicide, improvements are needed to effectively cull information to identify potential candidates for clinical trials, researchers from Ohio State University and elsewhere found.
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