Evidence map›Paper›PMID 42118974›Full record

ArticleJournal of the American Medical Informatics Association : JAMIA2026

What do clinicians edit in ambient AI-drafted clinical documentation? A qualitative content analysis.

Yawen Guo, Di Hu, Ziqi Yang, Seungjun Kim, Brian Tran, Jamie Lee, Sitha Vallabhaneni, Rachael Zehrung, Sairam Sutari, Steven Tam and 4 more

Abstract read
In one paragraph

Article in Journal of the American Medical Informatics Association : JAMIA, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 2 papers.

0numbers the graph read from it
0cells of the map it votes in
2citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from 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.

2 · The registry

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.

3 · Its place in the literature

Who cites it

2 citing papers in PubMed.

  1. Article
  2. Review
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

14 authors.

Yawen GuoDepartment of Informatics, University of California, Irvine, Irvine, CA 92617, United States.ORCID 0009-0006-2048-1798
Di HuDepartment of Informatics, University of California, Irvine, Irvine, CA 92617, United States.
Ziqi YangDepartment of Informatics, University of California, Irvine, Irvine, CA 92617, United States.ORCID 0009-0008-8064-7002
Seungjun KimDepartment of Informatics, University of California, Irvine, Irvine, CA 92617, United States.
Brian TranDepartment of Informatics, University of California, Irvine, Irvine, CA 92617, United States.ORCID 0000-0003-2342-700X
Jamie LeeDepartment of Informatics, University of California, Irvine, Irvine, CA 92617, United States.
Sitha VallabhaneniDepartment of Informatics, University of California, Irvine, Irvine, CA 92617, United States.
Rachael ZehrungDepartment of Informatics, University of California, Irvine, Irvine, CA 92617, United States.
Sairam SutariInstitute for Clinical and Translational Science, University of California, Irvine, Irvine, CA 92697, United States.
Steven TamDepartment of Medicine, University of California, Irvine, Irvine, CA 92617, United States.
Emilie ChowDepartment of Medicine, University of California, Irvine, Irvine, CA 92617, United States.
Danielle PerretDepartment of Physical Medicine & Rehabilitation, University of California, Irvine, Irvine, CA 92697, United States.
Deepti PanditaDepartment of Medicine, University of California, Irvine, Irvine, CA 92617, United States.
Kai ZhengDepartment of Informatics, University of California, Irvine, Irvine, CA 92617, United States.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

objectiveAmbient artificial intelligence (AI) documentation is increasingly used to draft clinical notes from patient-provider conversations, but how clinicians revise and finalize these drafts is not well understood. This qualitative content analysis study characterizes real-world edits to AI-generated drafts and identifies opportunities for improvement of AI design and the implementation process. MATERIALS AND

methodsEight coders analyzed clinical documentation generated by ambient AI from 200 clinical encounters. We developed an inductive coding framework with 11 codes across 3 categories: clinical content, terminology, and language style. Interrater reliability was assessed using Cohen's kappa. We then applied thematic analysis to synthesize patterns across the coded edits.

resultsThe most frequently edited content pertained to clinical facts including orders (eg, procedures, lab tests) (40.0%), symptoms (30.3%), medication prescriptions (27.3%), and diagnosis descriptions (25.9%). In comparison, edits related to terminology use (11.6%) and language style (7.2%) were less frequent. The results of our thematic analysis show that most edits can be categorized into one of the following 5 types: to revise factual discrepancies, to add medical specialty-specific details, to express diagnostic certainties, to convert patient expressions into objective assessments recorded in medical terms, and to reorganize or condense content. CONCLUSION AND DISCUSSION: Clinicians routinely revise ambient AI drafts to modify factual details and clinical specificity. Future work on AI development and clinical implementation should emphasize specialty customization and support personalized documentation practices, alongside clinician education that promotes robust and consistent review routines to ensure documentation quality.

Indexed as

Artificial IntelligenceClinical CodingDocumentationElectronic Health RecordsDocument AnalysisHumansQualitative ResearchTerminology as Topicambient listeningartificial intelligenceelectronic health records[E05.318.308.940.968.625.500]qualitative codingthematic analysis

Identifiers

PMID42118974
PMCPMC13386006

What OpenQuestion holds

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LicenceCC BY
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Registered trials

None linked

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.