ArticleApplied clinical informatics2013
Association of Medical Directors of Information Systems consensus on inpatient electronic health record documentation.
Article in Applied clinical informatics, 2013. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 34 papers, 1 of them a synthesis that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
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
34 citing papers in PubMed, 1 synthesis or guideline pooled 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
- Effect of Outpatient Note Templates on Note Quality: NOTE (Notation Optimization through Template Engineering) Randomized Clinical Trial.Journal of general internal medicine · 2021Trial
- Re-Centering Clinical Documentation in the Age of AI Scribes: Four Aims of the Patient Chart Note.JMIR medical education · 2026Article
- Enhancing Radiology Clinical Histories Through Transformer-Based Automated Clinical Note Summarization.Journal of imaging informatics in medicine · 2026Article
- The use of hybrid training in record documentation standards to improve medical record documentation in emergency departments: A quasiexperimental study.Journal of education and health promotion · 2026Article
- Addressing Note Bloat: Solutions for Effective Clinical Documentation.Journal of the American College of Emergency Physicians open · 2025Article
- Nurses' Perceptions and Recommendations on the Safe Use of "Copy and Paste" Function in an Electronic Medical Record of a National Tertiary Hospital.Acta medica Philippina · 2025Article
- Validating the Physician Documentation Quality Instrument for Intensive Care Unit-Ward Transfer Notes.ATS scholar · 2024Article
- Neonatal informatics: past, present and future.Journal of perinatology : official journal of the California Perinatal Association · 2024Article
- Impact of Electronic Health Record Use on Cognitive Load and Burnout Among Clinicians: Narrative Review.JMIR medical informatics · 2024Article
- Back to Babies: Reducing Documentation Time in the NICU.ACI open · 2024Article
- Progress Note Understanding - Assessment and Plan Reasoning: Overview of the 2022 N2C2 Track 3 shared task.Journal of biomedical informatics · 2023Article
- Copy-Pasting in Patients' Electronic Medical Records (EMRs): Use Judiciously and With Caution.Cureus · 2023Review
- Novel Note Templates to Enhance Signal and Reduce Noise in Medical Documentation: Prospective Improvement Study.JMIR formative research · 2023Article
- Summarizing Patients' Problems from Hospital Progress Notes Using Pre-trained Sequence-to-Sequence Models.Proceedings of COLING. International Conference on Computational Linguistics · 2022Article
- Disappearing Help Text: Implementing a Note-Based Tool for In-Line Clinical Decision Support and Note Bloat Reduction.Applied clinical informatics · 2022Article
- Hierarchical Annotation for Building A Suite of Clinical Natural Language Processing Tasks: Progress Note Understanding.LREC ... International Conference on Language Resources & Evaluation : [proceedings]. International Conference on Language Resources & Evaluation · 2022Article
- Usability challenges with electronic health records (EHRs) during prerounding on pediatric inpatients.JAMIA open · 2022Article
- Frequent but fragmented: use of note templates to document outpatient visits at an academic health center.Journal of the American Medical Informatics Association : JAMIA · 2021Article
- Length and Redundancy of Outpatient Progress Notes Across a Decade at an Academic Medical Center.JAMA network open · 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
4 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
In 2013, electronic documentation of clinical care stands at a crossroads. The benefits of creating digital notes are at risk of being overwhelmed by the inclusion of easily importable detail. Providers are the primary authors of encounters with patients. We must document clearly our understanding of patients and our communication with them and our colleagues. We want to document efficiently to meet without exceeding documentation guidelines. We copy and paste documentation, because it not only simplifies the documentation process generally, but also supports meeting coding and regulatory requirements specifically. Since the primary goal of our profession is to spend as much time as possible listening to, understanding and helping patients, clinicians need information technology to make electronic documentation easier, not harder. At the same time, there should be reasonable restrictions on the use of copy and paste to limit the growing challenge of 'note bloat'. We must find the right balance between ease of use and thoughtless documentation. The guiding principles in this document may be used to launch an interdisciplinary dialogue that promotes useful and necessary documentation that best facilitates efficient information capture and effective display.
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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.