Objective To design and validate a reliable instrument to assess the quality of physician documentation.

Design Adjectives describing clinician attitudes about high-quality clinical documentation were gathered through literature review, assessed by clinical experts, and transformed into a semantic differential scale. Using the scale, physicians and nurse practitioners scored the importance of the adjectives for describing quality in three note types: admission, progress, and discharge notes. Psychometric methods including exploratory factor analysis were applied to provide preliminary evidence for the construct validity and internal consistency reliability.

Results A 22-item, Physician Documentation Quality Instrument (PDQI) was developed. Exploratory factor analysis (n=67 clinician respondents) on three note types resulted in solutions ranging from four (discharge) to six factors (admission and progress), and explained 65.8% (discharge) to 73% (admission and progress) of the variance. Each factor solution was unique. However, four sets of items consistently factored together across all note types: 1) up-to-date and current; 2) brief, concise, succinct; 3) organized and structured; and 4) correct, comprehensible, consistent. Internal consistency reliabilities were: admission note (factor scales=.52-88, overall=.86), progress note (factor scales=.59-.84, overall=.87), and discharge summary (factor scales=.76-.85, overall=.88).

Conclusions The exploratory factor analyses and reliability analyses provide preliminary evidence for the construct validity and internal consistency reliability of the PDQI. Two novel dimensions of the construct for document quality were developed related to form (Well-formed, Compact). Additional work is needed to assess intra- and inter-rater reliability of applying of the proposed instrument and to examine the reproducibility of the factors in other samples.