BMJ Qual Saf 23:406-413 doi:10.1136/bmjqs-2013-002194
  • Original research

Association of note quality and quality of care: a cross-sectional study

  1. David W Bates3,4
  1. 1Massachusetts Veteran's Epidemiology Research and Information Center, Veteran's Affairs Boston Healthcare System, Boston, Massachusetts, USA
  2. 2Section of General Internal Medicine, Veteran's Affairs Boston Healthcare System, Boston, Massachusetts, USA
  3. 3Harvard Medical School, Boston, Massachusetts, USA
  4. 4Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
  5. 5Clinical Quality and Analysis, Partners Healthcare System, Wellesley, Massachusetts, USA
  1. Correspondence to Dr David W Bates, Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St., Boston, MA 02120, USA; dbates{at}
  • Received 30 May 2013
  • Revised 10 October 2013
  • Accepted 10 November 2013
  • Published Online First 28 November 2013


Background While physician notes are known to vary in organisation, content and quality, the relationship between note quality and clinical quality is uncertain.

Methods We performed a cross-sectional study of outpatient visit physician notes by adult patients with coronary artery disease or diabetes mellitus seen in 2010. We assessed physician note quality using the 9-item Physician Documentation Quality Instrument (PDQI-9) and compared this to disease-specific clinical quality scores constructed from data extracted from the electronic health record (EHR). We also assessed the presence of typical note subsections, and indicators of quality care in physician notes.

Results We evaluated 239 notes, written by 111 physicians; 110 notes were written by primary care physicians, 52 by cardiologists and 77 by endocrinologists. Reason for visit was absent in 10% of notes, medication list was not present in the note in 19.7% and timing for follow-up was absent in 18.0% of notes. Significant copy/pasted material was present in 10.5% of notes. Laboratory quality indicators were more often found in other EHR sections than in the physician note. Clinical quality scores for diabetes and coronary artery disease (CAD) showed no significant association with subjective note quality (diabetes: r −0.119, p=0.065, CAD: r −0.124, p=0.06).

Conclusions Notes varied in documentation method and length, and important note subsections were frequently missing. Key clinical data to support quality patient care were often not present in physician notes, but were often found elsewhere in the EHR. Subjective assessment of note quality did not correlate with clinical quality scores, suggesting that writing high-quality notes and meeting quality measures are not mutually reinforcing activities.

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