ArticleJournal of medical systems2022
The Impact of Structured and Standardized Documentation on Documentation Quality; a Multicenter, Retrospective Study.
Article in Journal of medical systems, 2022. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 71 papers, 1 of them a synthesis 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.
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Who cites it
71 citing papers in PubMed, 1 synthesis or guideline pooled it, 109 citations in OpenAlex.
- Evidence on artificial intelligence-assisted clinical documentation and healthcare workers' emotional wellbeing at work: a scoping review.Frontiers in psychology · 2026Pooled it
- An inpatient Serious Illness Care Program for older patients with hematologic malignancies: a single-arm pilot study.Blood advances · 2026Trial
- 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
- Improving patient communication and understanding of medical reports through text simplification with ChatGPT: a comparative study.Oral and maxillofacial surgery · 2026Article
- Why and how the long case became the OSLER-the sum of the parts.Irish journal of medical science · 2026Article
- User Experiences of Electronic Controlled Substance Surveillance Among Health Care Professionals in a Large Academic Hospital: Cross-Sectional Survey.Journal of medical Internet research · 2026Article
- Completeness of Paper-Based Clinical Records as a Dimension of Clinical Record Quality in Selected Public Hospitals in Mpumalanga and Eastern Cape Provinces, South Africa.Medical sciences (Basel, Switzerland) · 2026Article
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- The views of different care professionals on using an electronic health record in the care for older people.BMC geriatrics · 2026Article
- Inconsistencies in Clinical Reporting of Nasopharyngoscopy for Evaluating Velopharyngeal Closure: A Multisite Study.American journal of speech-language pathology · 2026Article
- The Framework of Policy Transition in TBI: From GCS to CBI-M.Neurocritical care · 2026Article
- Impact of a nurse anesthetist student-led training program on perioperative pain management in total knee replacement: A prospective before and after study.International journal of nursing studies advances · 2026Article
- Policy implementers' perspectives of the implementation of the national guidelines for patient safety incident reporting in selected South African public hospitals.BMC health services research · 2026Article
- Article
- Current practices in peer review in German radiation oncology: a nationwide survey.Strahlentherapie und Onkologie : Organ der Deutschen Rontgengesellschaft ... [et al] · 2026Article
- Optimal approach to standardized documentation in epilepsy clinics: A scoping review.Epilepsia · 2026Article
- A Retrospective Study of Adult and Pediatric D-Dimer Tests to Identify Opportunities for Improved Utilization.International journal of laboratory hematology · 2026Article
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- Article
- Expert consensus on multidisciplinary management of laparoscopic-endoscopic cooperative surgery combined with sentinel lymph node navigation surgery for early gastric cancer (2026 edition).Chinese journal of cancer research = Chung-kuo yen cheng yen chiu · 2026Article
11 more citing papers are in PubMed but not listed here.
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
10 authors at 2 institutions in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
The reuse of healthcare data for various purposes will become increasingly important in the future. To enable the reuse of clinical data, structured and standardized documentation is conditional. However, the primary purpose of clinical documentation is to support high-quality patient care. Therefore, this study investigated the effect of increased structured and standardized documentation on the quality of notes in the Electronic Health Record. A multicenter, retrospective design was used to assess the difference in note quality between 144 unstructured and 144 structured notes. Independent reviewers measured note quality by scoring the notes with the Qnote instrument. This instrument rates all note elements independently using and results in a grand mean score on a 0-100 scale. The mean quality score for unstructured notes was 64.35 (95% CI 61.30-67.35). Structured and standardized documentation improved the Qnote quality score to 77.2 (95% CI 74.18-80.21), a 12.8 point difference (p < 0.001). Furthermore, results showed that structured notes were significantly longer than unstructured notes. Nevertheless, structured notes were more clear and concise. Structured documentation led to a significant increase in note quality. Moreover, considering the benefits of structured data recording in terms of data reuse, implementing structured and standardized documentation into the EHR is recommended.
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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.