title: QNOTE: an instrument for measuring the quality of EHR clinical notes.
abstract: 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.
  
  
  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.
authors.affiliation: 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.
authors.forename: Harry B
authors.initials: HB
authors.lastname: Burke
authors.affiliation: Biomedical Informatics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Albert
authors.initials: A
authors.lastname: Hoang
authors.affiliation: Biomedical Informatics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Dorothy
authors.initials: D
authors.lastname: Becher
authors.affiliation: National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA.
authors.forename: Paul
authors.initials: P
authors.lastname: Fontelo
authors.affiliation: National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA.
authors.forename: Fang
authors.initials: F
authors.lastname: Liu
authors.affiliation: Family Medicine Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Stephens
authors.affiliation: Medicine Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Louis N
authors.initials: LN
authors.lastname: Pangaro
authors.affiliation: Medicine Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Laura L
authors.initials: LL
authors.lastname: Sessums
authors.affiliation: 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.
authors.forename: Patrick
authors.initials: P
authors.lastname: O'Malley
authors.affiliation: Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Nancy S
authors.initials: NS
authors.lastname: Baxi
authors.affiliation: Family Medicine Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Christopher W
authors.initials: CW
authors.lastname: Bunt
authors.affiliation: Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Vincent F
authors.initials: VF
authors.lastname: Capaldi
authors.affiliation: Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Julie M
authors.initials: JM
authors.lastname: Chen
authors.affiliation: Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Barbara A
authors.initials: BA
authors.lastname: Cooper
authors.affiliation: Fort Belvoir Community Hospital, Fort Belvoir, Virginia, USA.
authors.forename: David A
authors.initials: DA
authors.lastname: Djuric
authors.affiliation: Fort Belvoir Community Hospital, Fort Belvoir, Virginia, USA.
authors.forename: Joshua A
authors.initials: JA
authors.lastname: Hodge
authors.affiliation: Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Shawn
authors.initials: S
authors.lastname: Kane
authors.affiliation: Medicine Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Charles
authors.initials: C
authors.lastname: Magee
authors.affiliation: Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Zizette R
authors.initials: ZR
authors.lastname: Makary
authors.affiliation: Internal Medicine Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Renee M
authors.initials: RM
authors.lastname: Mallory
authors.affiliation: Family Medicine Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Miller
authors.affiliation: Family Medicine Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Adam
authors.initials: A
authors.lastname: Saperstein
authors.affiliation: Family Medicine Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Jessica
authors.initials: J
authors.lastname: Servey
authors.affiliation: Biomedical Informatics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
authors.forename: Ronald W
authors.initials: RW
authors.lastname: Gimbel
mesh_terms: D059019:Clinical Coding / Q000592:standards; D015510:Clinical Medicine / Q000592:standards*; D057286:Electronic Health Records / Q000592:standards*; D006772:Hospitals, Military; D006801:Humans; D010044:Outpatient Clinics, Hospital; D011320:Primary Health Care; D011786:Quality Control; D012189:Retrospective Studies; D014481:United States
keywords: Clinical Note; Clinical Quality; Electronic Health Record; Note Quality; QNOTE