ArticleJournal of the American Medical Informatics Association : JAMIA
Clinical documentation: composition or synthesis?
Article in Journal of the American Medical Informatics Association : JAMIA. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 53 papers, 3 of them syntheses that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
53 citing papers in PubMed, 3 syntheses or guidelines pooled it.
- Measuring Documentation Burden in Healthcare.Journal of general internal medicine · 2024Pooled it
- A systematic review of patient access to medical records in the acute setting: practicalities, perspectives and ethical consequences.BMC medical ethics · 2020Pooled it
- Safe Practices for Copy and Paste in the EHR. Systematic Review, Recommendations, and Novel Model for Health IT Collaboration.Applied clinical informatics · 2017Pooled it
- An electronic documentation system improves the quality of admission notes: a randomized trial.Journal of the American Medical Informatics Association : JAMIA · 2017Trial
- Multimodal integrated knowledge transfer to large language models through preference optimization with biomedical applications.Patterns (New York, N.Y.) · 2026Article
- Optimizing clinical documentation in virtual hospitals: a task-technology fit perspective.JAMIA open · 2026Article
- Article
- Shifting From Best Practice to Standard Practice: Implementing Measurement-Based Care in Health Systems.Child psychiatry and human development · 2025Review
- Verifiable Summarization of Electronic Health Records Using Large Language Models to Support Chart Review.medRxiv : the preprint server for health sciences · 2025Article
- Exploring Physicians' Dual Perspectives on the Transition From Free Text to Structured and Standardized Documentation Practices: Interview and Participant Observational Study.JMIR formative research · 2025Observational
- Evaluation and practical application of prompt-driven ChatGPTs for EMR generation.NPJ digital medicine · 2025Review
- Article
- Patient Information Summarization in Clinical Settings: Scoping Review.JMIR medical informatics · 2023Article
- Impact of Electronic Health Records on Information Practices in Mental Health Contexts: Scoping Review.Journal of medical Internet research · 2022Article
- Medical documentation practice and associated factors among health workers at private hospitals in the Amhara region, Ethiopia 2021.BMC health services research · 2022Article
- Workarounds in Electronic Health Record Systems and the Revised Sociotechnical Electronic Health Record Workaround Analysis Framework: Scoping Review.Journal of medical Internet research · 2022Article
- Automated Pulmonary Embolism Risk Assessment Using the Wells Criteria: Validation Study.JMIR formative research · 2022Article
- Characterizing styles of clinical note production and relationship to clinical work hours among first-year residents.Journal of the American Medical Informatics Association : JAMIA · 2021Article
- Electronic health record note review in an outpatient specialty clinic: who is looking?JAMIA open · 2021Article
- Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review.Journal of the American Medical Informatics Association : JAMIA · 2021Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
5 authors.
Funding
Abstract
objectiveTo understand the nature of emerging electronic documentation practices, disconnects between documentation workflows and computing systems designed to support them, and ways to improve the design of electronic documentation systems. MATERIALS AND
methodsTime-and-motion study of resident physicians' note-writing practices using a commercial electronic health record system that includes an electronic documentation module. The study was conducted in the general medicine unit of a large academic hospital.
resultsDuring the study, 96 note-writing sessions by 11 resident physicians, resulting in close to 100 h of observations were seen. Seven of the 10 most common transitions between activities during note composition were between documenting, and gathering and reviewing patient data, and updating the plan of care. DISCUSSION: The high frequency of transitions seen in the study suggested that clinical documentation is fundamentally a synthesis activity, in which clinicians review available patient data and summarize their impressions and judgments. At the same time, most electronic health record systems are optimized to support documentation as uninterrupted composition. This mismatch leads to fragmentation in clinical work, and results in inefficiencies and workarounds. In contrast, we propose that documentation can be best supported with tools that facilitate data exploration and search for relevant information, selective reading and annotation, and composition of a note as a temporal structure.
conclusionsTime-and-motion study of clinicians' electronic documentation practices revealed a high level of fragmentation of documentation activities and frequent task transitions. Treating documentation as synthesis rather than composition suggests new possibilities for supporting it more effectively with electronic systems.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.