ArticleApplied clinical informatics2014
A qualitative analysis evaluating the purposes and practices of clinical documentation.
Article in Applied clinical informatics, 2014. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 21 papers, 1 of them a synthesis that pooled it.
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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
21 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Clinicians' reasoning as reflected in electronic clinical note-entry and reading/retrieval: a systematic review and qualitative synthesis.Journal of the American Medical Informatics Association : JAMIA · 2019Pooled it
- Data-Driven Implementation Strategy to Optimise Clinician Behaviour Change at Scale in Complex Clinical Environments: A Multicentre Emergency Care Study.Journal of advanced nursing · 2025Trial
- Application of digital simulations for clinical assessment and documentation of temporomandibular disorders: a retrospective study.Oral surgery, oral medicine, oral pathology and oral radiology · 2026Article
- Advice From Adolescents With Cancer, Their Caregivers, and Clinicians on Utilizing and Improving Patient Portals in Adolescent Oncology Care.Pediatric blood & cancer · 2026Article
- 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
- Effect of an Electronic Health Record-Based Intervention on Documentation Practices.Applied clinical informatics · 2024Article
- Examining Linguistic Differences in Electronic Health Records for Diverse Patients With Diabetes: Natural Language Processing Analysis.JMIR medical informatics · 2024Article
- Early Performance of the Patients Over Paperwork Initiative among Family Medicine Physicians.Southern medical journal · 2023Article
- Reflections on the Documentation Burden Reduction AMIA Plenary Session through the Lens of 25 × 5.Applied clinical informatics · 2023Article
- Impact of Electronic Health Records on Information Practices in Mental Health Contexts: Scoping Review.Journal of medical Internet research · 2022Article
- Dental Recordkeeping: Practice in Federation of Bosnia and Herzegovina.Acta informatica medica : AIM : journal of the Society for Medical Informatics of Bosnia & Herzegovina : casopis Drustva za medicinsku informatiku BiH · 2021Article
- Novel Nonproprietary Measures of Ambulatory Electronic Health Record Use Associated with Physician Work Exhaustion.Applied clinical informatics · 2021Article
- Reducing Physicians' Cognitive Load During Chart Review: A Problem-Oriented Summary of the Patient Electronic Record.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2021Article
- Using big data to promote precision oral health in the context of a learning healthcare system.Journal of public health dentistry · 2020Review
- The anatomy of clinical documentation: an assessment and classification of narrative note sections format and content.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2020Article
- Unintended Consequences of Nationwide Electronic Health Record Adoption: Challenges and Opportunities in the Post-Meaningful Use Era.Journal of medical Internet research · 2019Article
- Completeness of Electronic Dental Records in a Student Clinic: Retrospective Analysis.JMIR medical informatics · 2019Article
- A hospital-wide transition from paper to digital problem-oriented clinical notes. A descriptive history and cross-sectional survey of use, usability, and satisfaction.Applied clinical informatics · 2017Article
- Tailoring implementation strategies for evidence-based recommendations using computerised clinical decision support systems: protocol for the development of the GUIDES tools.Implementation science : IS · 2016Article
- Turning Electromyography Reports Upside Down: A Pilot Study Surveying Referring Providers.The open medical informatics journal · 2016Article
Corrections and comments
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Authors and funding
4 authors.
Funding
Abstract
objectivesAn important challenge for biomedical informatics researchers is determining the best approach for healthcare providers to use when generating clinical notes in settings where electronic health record (EHR) systems are used. The goal of this qualitative study was to explore healthcare providers' and administrators' perceptions about the purpose of clinical documentation and their own documentation practices.
methodsWe conducted seven focus groups with a total of 46 subjects composed of healthcare providers and administrators to collect knowledge, perceptions and beliefs about documentation from those who generate and review notes, respectively. Data were analyzed using inductive analysis to probe and classify impressions collected from focus group subjects.
resultsWe observed that both healthcare providers and administrators believe that documentation serves five primary domains: clinical, administrative, legal, research, education. These purposes are tied closely to the nature of the clinical note as a document shared by multiple stakeholders, which can be a source of tension for all parties who must use the note. Most providers reported using a combination of methods to complete their notes in a timely fashion without compromising patient care. While all administrators reported relying on computer-based documentation tools to review notes, they expressed a desire for a more efficient method of extracting relevant data.
conclusionsAlthough clinical documentation has utility, and is valued highly by its users, the development and successful adoption of a clinical documentation tool largely depends on its ability to be smoothly integrated into the provider's busy workflow, while allowing the provider to generate a note that communicates effectively and efficiently with multiple stakeholders.
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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.