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J Am Med Inform Assoc. 2014 Sep-Oct;21(5):910-6. doi: 10.1136/amiajnl-2013-002321. Epub 2014 Jan 2.

QNOTE: an instrument for measuring the quality of EHR clinical notes.

Author information

1
Biomedical Informatics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA Medicine Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
2
Biomedical Informatics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
3
National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA.
4
Family Medicine Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
5
Medicine Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
6
Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
7
Fort Belvoir Community Hospital, Fort Belvoir, Virginia, USA.

Abstract

BACKGROUND AND OBJECTIVE:

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. This study 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.

MATERIALS AND METHODS:

Retrospective multicenter blinded study of the clinical notes of 100 outpatients with type 2 diabetes mellitus who had been seen in clinic on at least three occasions. 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.

RESULTS:

The overall QNOTE inter-rater agreement was 0.82 (CI 0.80 to 0.84), and its note quality score was 65 (CI 64 to 66). The Global inter-rater agreement was 0.24 (CI 0.19 to 0.29), and its note quality score was 52 (CI 49 to 55). The QNOTE quality scores were consistent, and the overall QNOTE score was significantly higher than the overall Global score (p=0.04).

CONCLUSIONS:

We found the QNOTE to be a valid instrument for evaluating the quality of electronic clinical notes, and its performance was superior to that of the Global instrument.

KEYWORDS:

Clinical Note; Clinical Quality; Electronic Health Record; Note Quality; QNOTE

PMID:
24384231
PMCID:
PMC4147610
DOI:
10.1136/amiajnl-2013-002321
[Indexed for MEDLINE]
Free PMC Article

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