News Feature | January 10, 2014

Digital Tool Assesses Clinical Notes

Source: Health IT Outcomes
Katie Wike

By Katie Wike, contributing writer

HITO Doctor Taking Notes

QNOTE assesses electronic clinical notes to determine the quality of the visit and the strength of doctors’ notes

A Uniformed Services University of the Health Sciences study published by the Journal of the American Informatics Association “evaluated the validity of the QNOTE instrument, which assesses 12 elements in the clinical note, for measuring the quality of clinical notes. It also compared its performance with a global instrument that assesses the clinical note as a whole.” Researchers conducted the study because, “The outpatient clinical note documents the clinician's information collection, problem assessment, and patient management, yet there is currently no validated instrument to measure the quality of the electronic clinical note.”

FierceHealthIT notes patient care is improved with “quality clinical notes” and lists three key functions these type of notes serve as:

  • documenting the clinician's information collection, problem assessment, and plan for the patient
  • creating a complete and accurate record that can be used by other clinicians to care for the patient;
  • providing substantiation for what was done for legal reasons and reimbursement

“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,” explains FierceHealthIT. “Each element is assessed using seven criteria: whether each is clear, complete, concise, current, organized, prioritized and contains sufficient information.”

The study looked at “the clinical notes of 100 outpatients with type 2 diabetes mellitus who had been seen in clinic on at least three occasions,” according to the abstract. “The 300 notes were rated by eight general internal medicine and eight family medicine practicing physicians. The QNOTE instrument scored the quality of the note as the sum of a set of 12 note element scores, and its inter-rater agreement was measured by the intraclass correlation coefficient. The Global instrument scored the note in its entirety, and its inter-rater agreement was measured by the Fleiss κ.”

Study authors concluded, “The QNOTE instrument has been shown to possess external validity and, in this study, it demonstrated high internal validity. 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. The QNOTE instrument provides a structured, easy to use, transparent, valid, and reliable way to assess the quality of electronic clinical notes.”

EHR Intelligence reviewed the study and opines, “Considering the importance assigned to clinical notes by physicians, the ability to assess these accounts of clinical encounters should prove valuable in efforts to improve the quality of care and in turn patient outcomes, both of which are key aims of a shift toward pay-for-performance payments (i.e., accountable care).”

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