Toward Efficient, Sustainable, and Scalable Methods of Treatment Characterization: An Investigation of Coding Clinical Practice from Chart Notes.

Purpose: Chart notes provide a low-cost data source that could help characterize what occurs in treatment with sufficient precision to improve management of care. This study assessed the interrater reliability of treatment content coded from chart notes and evaluated its concordance with content coded from transcribed treatment sessions.

Method: Fifty randomly selected and digitally recorded treatment events were transcribed and coded for practice content. Independent coders then applied the same code system to chart notes for these same treatment events.

Analysis: We measured reliability and concordance of practice occurrence and extensiveness at two levels of specificity: practices (full procedures) and steps (subcomponents of those procedures).

Results: For chart notes, practices had moderate interrater reliability (M k = 0.50, M ICC = 0.56) and steps had moderate (M ICC = 0.74) to substantial interrater reliability (M k = 0.78). On average, 2.54 practices and 5.64 steps were coded per chart note and 4.53 practices and 13.10 steps per transcript. Across sources, ratings for 64% of practices and 41% of steps correlated significantly, with those with significant correlations generally demonstrating moderate concordance (practice M r = 0.48; step M r = 0.47). Forty one percent of practices and 34% of steps from transcripts were also identified in the corresponding chart notes.

Conclusion: Chart notes provide an accessible data source for evaluating treatment content, with different levels of specificity posing tradeoffs for validity and reliability, which in turn may have implications for chart note interfaces, training, and new metrics to support accurate, reliable, and efficient measurement of clinical practice.