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The anatomy of clinical documentation: an assessment and classification of narrative note sections format and content

Introduction. We systematically analyzed the most commonly used narrative note formats and content found in primary and specialty care visit notes to inform future research and electronic health record (EHR) development. Methods. We extracted data from the history of present illness (HPI) and impression and plan (IP) sections of 80 primary and specialty care visit notes. Two authors iteratively classified the format of the sections and compared the size of each section and the overall note size between primary and specialty care notes. We then annotated the content of these sections to develop a taxonomy of types of data communicated in the narrative note sections. Results. Both HPI and IP were significantly longer in primary care when compared to specialty care notes (HPI: n = 187 words, SD[130] vs. n = 119 words, SD [53]; p = 0.004 / IP: n = 270 words, SD [145] vs. n = 170 words, SD [101]; p < 0.001). Although we did not find a significant difference in the overall note size between the two groups, the proportion of HPI and IP content in relation to the total note size was significantly higher in primary care notes (40%, SD [13] vs. 28%, SD [11]; p < 0.001). We identified five combinations of format of HPI + IP sections respectively: (A) story + list with categories; (B) story + story; (C) list without categories + list with categories; (D) list with categories + list with categories; and (E) list with categories + story. HPI and IP content was significantly smaller in combination C compared to combination A (-172 words, [95% Conf. -326, -17.89]; p = 0.02). We identified seven taxa representing 45 different types of data: finding/condition documented (n = 14), intervention documented (n = 9), general descriptions and definitions (n = 7), temporal information (n = 6), reasons and justifications (n = 4), participants and settings (n = 4), and clinical documentation (n = 1). Conclusion. We identified commonly used narrative note section formats and developed a taxonomy of narrative note content to help researchers to tailor their efforts and design more efficient clinical documentation systems.