ArticleBMC medical informatics and decision making2022
Clinician documentation of patient centered care in the electronic health record.
Article in BMC medical informatics and decision making, 2022. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 9 papers.
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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.
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Who cites it
9 citing papers in PubMed, 12 citations in OpenAlex.
- Clinical Notes Contain Limited Documentation of Shared Decision Making for Colorectal Cancer Screening Decisions.Medical decision making : an international journal of the Society for Medical Decision Making · 2025Trial
- Patient-Centered Summarization Framework for AI Clinical Summarization: Mixed Methods Study.Journal of medical Internet research · 2026Article
- User-centered design of a patient-generated health data mobile application for primary care visits for older adults with chronic pain.JAMIA open · 2026Article
- An Informatics Approach to Characterizing Rarely Documented Clinical Information in Electronic Health Records: Spiritual Care as an Exemplar.Applied clinical informatics · 2025Article
- How is individualized nursing care documented in nursing records of cancer patients: A qualitative content analysis.BMC nursing · 2025Article
- Article
- The Age-Friendly Learning Healthcare System: Replicating electronic health record based documentation metrics for 4Ms care.Journal of the American Geriatrics Society · 2025Article
- The Impact of Collaborative Documentation on Person-Centered Care: Textual Analysis of Clinical Notes.JMIR medical informatics · 2024Article
- Article
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Authors and funding
10 authors at 2 institutions in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundIn this study we sought to explore the possibility of using patient centered care (PCC) documentation as a measure of the delivery of PCC in a health system.
methodsWe first selected 6 VA medical centers based on their scores for a measure of support for self-management subscale from a national patient satisfaction survey (the Survey for Healthcare Experience-Patients). We accessed clinical notes related to either smoking cessation or weight management consults. We then annotated this dataset of notes for documentation of PCC concepts including: patient goals, provider support for goal progress, social context, shared decision making, mention of caregivers, and use of the patient's voice. We examined the association of documentation of PCC with patients' perception of support for self-management with regression analyses.
resultsTwo health centers had < 50 notes related to either tobacco cessation or weight management consults and were removed from further analysis. The resulting dataset includes 477 notes related to 311 patients total from 4 medical centers. For a majority of patients (201 out of 311; 64.8%) at least one PCC concept was present in their clinical notes. The most common PCC concepts documented were patient goals (patients n = 126; 63% clinical notes n = 302; 63%), patient voice (patients n = 165, 82%; clinical notes n = 323, 68%), social context (patients n = 105, 52%; clinical notes n = 181, 38%), and provider support for goal progress (patients n = 124, 62%; clinical notes n = 191, 40%). Documentation of goals for weight loss notes was greater at health centers with higher satisfaction scores compared to low. No such relationship was found for notes related to tobacco cessation.
conclusionProviders document PCC concepts in their clinical notes. In this pilot study we explored the feasibility of using this data as a means to measure the degree to which care in a health center is patient centered. PRACTICE IMPLICATIONS: clinical EHR notes are a rich source of information about PCC that could potentially be used to assess PCC over time and across systems with scalable technologies such as natural language processing.
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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.