Association of note quality and quality of care: a cross-sectional study.
Approach to Improving Safety
Setting of Care
This study describes the content and structure of physician notes written by general internists, cardiologists, and endocrinologists while providing care for patients with diabetes or coronary artery disease. The authors hypothesized that high-quality notes would be associated with high-quality care, but this did not bear out in their results. Although length varied widely, on average, notes were between 536 and 659 words each. Evaluation of note quality revealed many gaps, including the lack of key information. Copy-and-pasted material was quite common overall. Some data supporting high-quality care, such as laboratory values, were found in areas of the electronic health record outside of the physician notes. Even though this study demonstrated significant room for note standardization and improvement, it found no clear relationship between physician note quality and appropriate care delivery.