SynthesisJournal of the American Medical Informatics Association : JAMIA2019
Clinicians' reasoning as reflected in electronic clinical note-entry and reading/retrieval: a systematic review and qualitative synthesis.
Synthesis in Journal of the American Medical Informatics Association : JAMIA, 2019. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 40 papers, 2 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
40 citing papers in PubMed, 2 syntheses or guidelines pooled it.
- Supporting clinical reasoning through visual summarization and presentation of patient data: a systematic review.Journal of the American Medical Informatics Association : JAMIA · 2025Pooled it
- Using clinical reasoning ontologies to make smarter clinical decision support systems: a systematic review and data synthesis.Journal of the American Medical Informatics Association : JAMIA · 2020Pooled it
- Diagnostic Anchoring on Positive Autoimmune Serologies in Polysymptomatic Patients.Journal of general internal medicine · 2026Article
- A Review on Artificial Intelligence as a Solution to Burnout in Interventional Radiology.Cardiovascular and interventional radiology · 2026Review
- Clinicians' rationale for editing ambient AI-drafted clinical notes: persistent challenges and implications for improvement.Journal of the American Medical Informatics Association : JAMIA · 2026Article
- Re-Centering Clinical Documentation in the Age of AI Scribes: Four Aims of the Patient Chart Note.JMIR medical education · 2026Article
- Large language model-augmented offline reinforcement learning framework for sepsis management in critical care.NPJ digital medicine · 2026Article
- Exploring nurses' documentation prioritization strategies to alleviate EHR documentation burden: a phenomenological study.JAMIA open · 2026Article
- Choosing between Patient Care Needs and Accurate Data Capture: Exploring Nurses' Experiences of Excessive Documentation Burden.Applied clinical informatics · 2025Article
- Quantitative Analysis of Diagnostic Reasoning Using Initial Electronic Medical Records.Diagnostics (Basel, Switzerland) · 2025Article
- "The start of something that I hope could be greater": Health information technology tools for social care.SSM. Qualitative research in health · 2025Article
- In pursuit of the alert fatigue: an assessment of drug alert burden at a large academic medical center.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2024Article
- Generative AI Demonstrated Difficulty Reasoning on Nursing Flowsheet Data.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2024Article
- Documentation dynamics: Note composition, burden, and physician efficiency.Health services research · 2023Article
- Physicians' Perspectives on a Multi-Dimensional Model for the Roles of Electronic Health Records in Approaching a Proper Differential Diagnosis.Journal of personalized medicine · 2023Article
- Novel Note Templates to Enhance Signal and Reduce Noise in Medical Documentation: Prospective Improvement Study.JMIR formative research · 2023Article
- Early Performance of the Patients Over Paperwork Initiative among Family Medicine Physicians.Southern medical journal · 2023Article
- Article
- Development and Validation of a Machine Learning Model for Automated Assessment of Resident Clinical Reasoning Documentation.Journal of general internal medicine · 2022Article
- Clinician documentation of patient centered care in the electronic health record.BMC medical informatics and decision making · 2022Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
2 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
Objective: To describe the literature exploring the use of electronic health record (EHR) systems to support creation and use of clinical documentation to guide future research. Materials and Methods: We searched databases including MEDLINE, Scopus, and CINAHL from inception to April 20, 2018, for studies applying qualitative or mixed-methods examining EHR use to support creation and use of clinical documentation. A qualitative synthesis of included studies was undertaken. Results: Twenty-three studies met the inclusion criteria and were reviewed in detail. We briefly reviewed 9 studies that did not meet the inclusion criteria but provided recommendations for EHR design. We identified 4 key themes: purposes of electronic clinical notes, clinicians' reasoning for note-entry and reading/retrieval, clinicians' strategies for note-entry, and clinicians' strategies for note-retrieval/reading. Five studies investigated note purposes and found that although patient care is the primary note purpose, non-clinical purposes have become more common. Clinicians' reasoning studies (n = 3) explored clinicians' judgement about what to document and represented clinicians' thought process in cognitive pathways. Note-entry studies (n = 6) revealed that what clinicians document is affected by EHR interfaces. Lastly, note-retrieval studies (n = 12) found that "assessment and plan" is the most read note section and what clinicians read is affected by external stimuli, care/information goals, and what they know about the patient. Conclusion: Despite the widespread adoption of EHRs, their use to support note-entry and reading/retrieval is still understudied. Further research is needed to investigate approaches to capture and represent clinicians' reasoning and improve note-entry and retrieval/reading.
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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.