title: The natural language of the surgeon's clinical note in outcomes assessment: a qualitative analysis of the medical record.
abstract: BACKGROUND
  Physician-generated clinical notes are the central document in recording the clinical decision-making and outcome of care. This is particularly true in an environment where outcomes assessment is becoming increasingly important. The hypothesis of this study is that these notes are inadequate to assess patient-centered outcomes and determine surgeons' core competencies.
  
  
  METHODS
  We preformed a retrospective review of postoperative clinical notes of general surgery patients for a 1-month period. Information from these notes underwent qualitative analysis using the reductionist thematic approach for patient-centered and physician-centered outcomes. Outcomes included 2 physician-centered items (physical examination and objective tests) and 3 patient-centered items (postoperative complications, functional status, and satisfaction). The presence or absence of each item in the clinical note was recorded.
  
  
  RESULTS
  Six hundred eighty-one patients of 18 general surgeons were included. Among the surgeons, 28% failed to document symptomatic change in even 1 patient; similarly, 67% failed to document functional change, and 50% failed to document satisfaction. Among all 681 clinical notes only 7% of records mentioned symptomatic change, 1% functional change, 87% physical examination, 26% objective tests, and 3% patient satisfaction. These results were not affected by procedure type or number of patients seen.
  
  
  CONCLUSIONS
  In general surgery practice, the surgeon's clinical note is a poor measure of physician-centered or patient-centered outcomes, implying that an audit of clinical notes would be an inaccurate method to assess patient outcomes. This has implications for issues surrounding maintenance of certification.
authors.affiliation: Division of General Surgery, K-8, Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI 48202, USA.
authors.forename: J Michael
authors.initials: JM
authors.lastname: Miller
authors.forename: Vic
authors.initials: V
authors.lastname: Velanovich
mesh_terms: D002568:Certification; D002983:Clinical Competence; D003955:Diagnostic Tests, Routine; D004282:Documentation; D013502:General Surgery; D006801:Humans; D008501:Medical Records, Problem-Oriented; D017063:Outcome Assessment, Health Care; D017060:Patient Satisfaction; D010808:Physical Examination; D011787:Quality of Health Care; D012189:Retrospective Studies