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

Abstract

Background and objectiveThe 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 methodsRetrospective 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.ResultsThe 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).ConclusionsWe 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.

The effectiveness of a bundled intervention to improve resident progress notes in an electronic health record

“…Hanson performed a qualitative study to describe outpatient clinical notes from the perspective of multiple stakeholders, resulting in a description of the characteristics of a quality note . This formed the basis for the QNOTE, a validated tool to measure the quality of outpatient notes . Similar work has not been done to rigorously define quality for inpatient documentation.…”

“…21 This formed the basis for the QNOTE, a validated tool to measure the quality of outpatient notes. 22 Similar work has not been done to rigorously define quality for inpatient documentation. Stetson did develop an instrument, the Physician Documenta-tion Quality Instrument (PDQI-9) to assess inpatient notes across 9 attributes; however, the validation method relied on a gold standard of a general impression score of 7 physician leaders.…”

Simulation of patient flow in multiple healthcare units using process and data mining techniques for model identification

“…Mostly, works in this area are focused on systematizing of qualitative and quantitative metrics, as well as detecting and assessment procedures. Considering EHR as a key data source leads to extended attention to the development of approaches and metrics for assessment and analysis of its quality [89,90].…”

Use of dictation as a tool to decrease documentation errors in electronic health records

“…One of them is the use of electronic medical records (EMR). The use of EMR among health care providers is rapidly increasing [1,2]. The use of EMR has been shown to improve the quality of medical documentation and also reduce both medical error and mortality rates [3–6].…”