{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,9]],"date-time":"2026-06-09T08:39:05Z","timestamp":1780994345097,"version":"3.54.1"},"reference-count":63,"publisher":"Oxford University Press (OUP)","issue":"2","license":[{"start":{"date-parts":[[2018,12,20]],"date-time":"2018-12-20T00:00:00Z","timestamp":1545264000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/journals\/pages\/open_access\/funder_policies\/chorus\/standard_publication_model"}],"funder":[{"name":"Informatics Institute of the University of Alabama at Birmingham"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2019,2,1]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Objective<\/jats:title><jats:p>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.<\/jats:p><\/jats:sec><jats:sec><jats:title>Materials and Methods<\/jats:title><jats:p>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.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>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\u2019 reasoning for note-entry and reading\/retrieval, clinicians\u2019 strategies for note-entry, and clinicians\u2019 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\u2019 reasoning studies (n\u2009=\u20093) explored clinicians\u2019 judgement about what to document and represented clinicians\u2019 thought process in cognitive pathways. Note-entry studies (n\u2009=\u20096) revealed that what clinicians document is affected by EHR interfaces. Lastly, note-retrieval studies (n\u2009=\u200912) found that \u201cassessment and plan\u201d 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.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>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\u2019 reasoning and improve note-entry and retrieval\/reading.<\/jats:p><\/jats:sec>","DOI":"10.1093\/jamia\/ocy155","type":"journal-article","created":{"date-parts":[[2018,10,27]],"date-time":"2018-10-27T19:08:48Z","timestamp":1540667328000},"page":"172-184","source":"Crossref","is-referenced-by-count":47,"title":["Clinicians\u2019 reasoning as reflected in electronic clinical note-entry and reading\/retrieval: a systematic review and qualitative synthesis"],"prefix":"10.1093","volume":"26","author":[{"given":"Tiago K","family":"Colicchio","sequence":"first","affiliation":[{"name":"Informatics Institute, University of Alabama at Birmingham, Birmingham, Alabama, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James J","family":"Cimino","sequence":"additional","affiliation":[{"name":"Informatics Institute, University of Alabama at Birmingham, Birmingham, Alabama, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2018,12,20]]},"reference":[{"key":"2020110613055107500_ocy155-B1","volume-title":"Social Organization of Medical Work","author":"Strauss","year":"1985"},{"issue":"6","key":"2020110613055107500_ocy155-B2","doi-asserted-by":"crossref","first-page":"503","DOI":"10.1007\/s10606-016-9261-x","article-title":"Cooperative epistemic work in medical practice: an analysis of physicians\u2019 clinical notes","volume":"25","author":"Bansler","year":"2016","journal-title":"Comput Support Coop Work"},{"key":"2020110613055107500_ocy155-B3"},{"key":"2020110613055107500_ocy155-B4","author":"Hammond"},{"issue":"1","key":"2020110613055107500_ocy155-B5","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1197\/jamia.M3390","article-title":"Quantifying clinical narrative redundancy in an electronic health record","volume":"17","author":"Wrenn","year":"2010","journal-title":"J Am Med Inform Assoc"},{"issue":"2","key":"2020110613055107500_ocy155-B6","doi-asserted-by":"crossref","first-page":"112","DOI":"10.1136\/jamia.2010.008441","article-title":"Use of electronic clinical documentation: time spent and team interactions","volume":"18","author":"Hripcsak","year":"2011","journal-title":"J Am Med Inform Assoc"},{"issue":"9","key":"2020110613055107500_ocy155-B7","doi-asserted-by":"crossref","first-page":"901","DOI":"10.1001\/jama.2017.0076","article-title":"Addressing physician burnout: the way forward","volume":"317","author":"Shanafelt","year":"2017","journal-title":"JAMA"},{"issue":"5","key":"2020110613055107500_ocy155-B8","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1370\/afm.2121","article-title":"Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations","volume":"15","author":"Arndt","year":"2017","journal-title":"Ann Fam Med"},{"key":"2020110613055107500_ocy155-B9","doi-asserted-by":"crossref","DOI":"10.7326\/M18-0139","article-title":"Physician burnout in the electronic health record era: are we ignoring the real cause?","volume-title":"Ann Intern Med","author":"Downing","year":"2018"},{"issue":"1","key":"2020110613055107500_ocy155-B10","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1007\/s11606-008-0843-2","article-title":"Physicians\u2019 attitudes towards copy and pasting in electronic note writing","volume":"24","author":"O'Donnell","year":"2009","journal-title":"J Gen Intern Med"},{"issue":"11","key":"2020110613055107500_ocy155-B11","doi-asserted-by":"crossref","first-page":"593","DOI":"10.1056\/NEJM196803142781105","article-title":"Medical records that guide and teach","volume":"278","author":"Weed","year":"1968","journal-title":"N Engl J Med"},{"key":"2020110613055107500_ocy155-B12","author":"Cimino","year":"2018"},{"key":"2020110613055107500_ocy155-B13","first-page":"763","article-title":"Toward medical documentation that enhances situational awareness learning","volume":"2016","author":"Lenert","year":"2016","journal-title":"AMIA Annu Symp Proc"},{"issue":"1","key":"2020110613055107500_ocy155-B14","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1518\/001872095779049543","article-title":"Toward a theory of situation awareness in dynamic systems","volume":"37","author":"Endsley","year":"1995","journal-title":"Hum Factors"},{"issue":"1","key":"2020110613055107500_ocy155-B15","doi-asserted-by":"crossref","first-page":"154","DOI":"10.1136\/amiajnl-2012-001351","article-title":"A systematic review of the literature on the evaluation of handoff tools: implications for research and practice","volume":"21","author":"Abraham","year":"2014","journal-title":"J Am Med Inform Assoc"},{"issue":"2","key":"2020110613055107500_ocy155-B16","doi-asserted-by":"crossref","first-page":"174","DOI":"10.4300\/JGME-D-14-00205.1","article-title":"Evaluating outcomes of electronic tools supporting physician shift-to-shift handoffs: a systematic review","volume":"7","author":"Davis","year":"2015","journal-title":"J Grad Med Educ"},{"issue":"1","key":"2020110613055107500_ocy155-B17","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1016\/j.surg.2015.02.017","article-title":"Effectiveness of interventions to improve patient handover in surgery: a systematic review","volume":"158","author":"Pucher","year":"2015","journal-title":"Surgery"},{"issue":"5","key":"2020110613055107500_ocy155-B18","doi-asserted-by":"crossref","first-page":"403","DOI":"10.1136\/bmjqs.2009.034587","article-title":"The efficacy of computer-enabled discharge communication interventions: a systematic review","volume":"20","author":"Motamedi","year":"2011","journal-title":"BMJ Qual Saf"},{"issue":"1","key":"2020110613055107500_ocy155-B19","first-page":"12","article-title":"Safe practices for copy and paste in the EHR","volume":"8","author":"Tsou","year":"2017","journal-title":"Appl Clin Inform"},{"issue":"4","key":"2020110613055107500_ocy155-B20","doi-asserted-by":"crossref","first-page":"264","DOI":"10.7326\/0003-4819-151-4-200908180-00135","article-title":"Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement","volume":"151","author":"Moher","year":"2009","journal-title":"Ann Intern Med"},{"key":"2020110613055107500_ocy155-B21"},{"key":"2020110613055107500_ocy155-B22","author":"Critical Appraisal Skills Programme","year":"2014"},{"issue":"6997","key":"2020110613055107500_ocy155-B23","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1136\/bmj.311.6997.109","article-title":"Research: rigour and qualitative research","volume":"311","author":"Mays","year":"1995","journal-title":"BMJ"},{"issue":"3","key":"2020110613055107500_ocy155-B24","doi-asserted-by":"crossref","first-page":"252","DOI":"10.1111\/medu.12092","article-title":"Qualitative synthesis and systematic review in health professions education: qualitative synthesis and systematic review","volume":"47","author":"Bearman","year":"2013","journal-title":"Med Educ"},{"issue":"1","key":"2020110613055107500_ocy155-B25","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1186\/1471-2288-9-59","article-title":"Methods for the synthesis of qualitative research: a critical review","volume":"9","author":"Barnett-Page","year":"2009","journal-title":"BMC Med Res Methodol"},{"issue":"2","key":"2020110613055107500_ocy155-B26","doi-asserted-by":"crossref","first-page":"432","DOI":"10.1093\/jamia\/ocw119","article-title":"A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care","volume":"24","author":"Brown","year":"2017","journal-title":"J Am Med Inform Assoc"},{"issue":"3","key":"2020110613055107500_ocy155-B27","doi-asserted-by":"crossref","first-page":"428","DOI":"10.1007\/s11414-015-9472-9","article-title":"Providers\u2019 note-writing practices for post-traumatic stress disorder at five United States Veterans Affairs facilities","volume":"43","author":"Tuepker","year":"2016","journal-title":"J Behav Health Serv Res"},{"issue":"1","key":"2020110613055107500_ocy155-B28","doi-asserted-by":"crossref","first-page":"153","DOI":"10.4338\/ACI-2013-10-RA-0081","article-title":"A qualitative analysis evaluating the purposes and practices of clinical documentation","volume":"5","author":"Ho","year":"2014","journal-title":"Appl Clin Inform"},{"issue":"3","key":"2020110613055107500_ocy155-B29","doi-asserted-by":"crossref","first-page":"304","DOI":"10.4338\/ACI-2010-04-RA-0023","article-title":"Evaluation of computerized free text sign-out notes","volume":"1","author":"Campion","year":"2010","journal-title":"Appl Clin Inform"},{"issue":"6","key":"2020110613055107500_ocy155-B30","doi-asserted-by":"crossref","first-page":"1136","DOI":"10.1016\/j.jbi.2013.08.009","article-title":"Effects of time constraints on clinician\u2013computer interaction: a study on information synthesis from EHR clinical notes","volume":"46","author":"Farri","year":"2013","journal-title":"J Biomed Inform"},{"issue":"6","key":"2020110613055107500_ocy155-B31","doi-asserted-by":"crossref","first-page":"758","DOI":"10.3122\/jabfm.2017.06.170194","article-title":"Information transfer and the hospital discharge summary: national primary care provider perspectives of challenges and opportunities","volume":"30","author":"Robelia","year":"2017","journal-title":"J Am Board Fam Med"},{"issue":"04","key":"2020110613055107500_ocy155-B32","doi-asserted-by":"crossref","first-page":"1117","DOI":"10.4338\/ACI-2017-06-RA-0110","article-title":"Health IT usability focus section: data use and navigation patterns among medical ICU clinicians during electronic chart review","volume":"08","author":"Nolan","year":"2017","journal-title":"Appl Clin Inform"},{"issue":"1","key":"2020110613055107500_ocy155-B33","first-page":"23","article-title":"How are allied health notes used for inpatient care and clinical decision-making? A qualitative exploration of the views of doctors, nurses and allied health professionals","volume":"46","author":"Pain","year":"2017","journal-title":"Health Inf Manag"},{"issue":"3","key":"2020110613055107500_ocy155-B34","doi-asserted-by":"crossref","first-page":"316","DOI":"10.3122\/jabfm.2015.03.140244","article-title":"Physician information needs and Electronic Health Records (EHRs): time to reengineer the clinic note","volume":"28","author":"Koopman","year":"2015","journal-title":"J Am Board Fam Med"},{"key":"2020110613055107500_ocy155-B35","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1016\/j.ijmedinf.2016.06.005","article-title":"Characteristics of outpatient clinical summaries in the United States","volume":"94","author":"Salmon","year":"2016","journal-title":"Int J Med Inform"},{"key":"2020110613055107500_ocy155-B36","first-page":"1211","article-title":"A qualitative analysis of EHR clinical document synthesis by clinicians","volume":"2012","author":"Farri","year":"2012","journal-title":"AMIA Annu Symp Proc"},{"issue":"12","key":"2020110613055107500_ocy155-B37","doi-asserted-by":"crossref","first-page":"1830","DOI":"10.1016\/j.spinee.2017.06.009","article-title":"Examination to assess the clinical examination and documentation of spine pathology among orthopedic residents","volume":"17","author":"Haglin","year":"2017","journal-title":"Spine J"},{"key":"2020110613055107500_ocy155-B38","first-page":"1879","article-title":"Physician-driven management of patient progress notes in an intensive care unit","volume":"2010","author":"Wilcox","year":"2010","journal-title":"Proc SIGCHI Conf Hum Factor Comput Syst"},{"issue":"6","key":"2020110613055107500_ocy155-B39","doi-asserted-by":"crossref","first-page":"569","DOI":"10.1136\/jamia.2000.0070569","article-title":"Impact of a computer-based patient record system on data collection, knowledge organization, and reasoning","volume":"7","author":"Patel","year":"2000","journal-title":"J Am Med Inform Assoc"},{"key":"2020110613055107500_ocy155-B40","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.ijmedinf.2016.02.011","article-title":"A comparative observational study of inpatient clinical note-entry and reading\/retrieval styles adopted by physicians","volume":"90","author":"Rizvi","year":"2016","journal-title":"Int J Med Inform"},{"issue":"1\u20132","key":"2020110613055107500_ocy155-B41","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1016\/S1532-0464(03)00058-3","article-title":"Assessing explicit error reporting in the narrative electronic medical record using keyword searching","volume":"36","author":"Cao","year":"2003","journal-title":"J Biomed Inform"},{"key":"2020110613055107500_ocy155-B42","first-page":"766","article-title":"Use of simulated physician handoffs to study cross-cover chart biopsy in the electronic medical record","volume":"2013","author":"Kendall","year":"2013","journal-title":"AMIA Annu Symp Proc"},{"issue":"3","key":"2020110613055107500_ocy155-B43","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1177\/1460458211405809","article-title":"Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses\u2019 handoffs on medical and surgical units: insights from interviews and observations","volume":"17","author":"Staggers","year":"2011","journal-title":"Health Informatics J"},{"issue":"12","key":"2020110613055107500_ocy155-B44","doi-asserted-by":"crossref","first-page":"958","DOI":"10.1016\/j.ijmedinf.2014.08.010","article-title":"Does an integrated emergency department information system change the sequence of clinical work? A mixed-method cross-site study","volume":"83","author":"Callen","year":"2014","journal-title":"Int J Med Inform"},{"issue":"4","key":"2020110613055107500_ocy155-B45","doi-asserted-by":"crossref","first-page":"912","DOI":"10.4338\/ACI-2016-03-RA-0033","article-title":"Toward designing information display to support critical care","volume":"7","author":"Wright","year":"2016","journal-title":"Appl Clin Inform"},{"issue":"2","key":"2020110613055107500_ocy155-B46","doi-asserted-by":"crossref","first-page":"260","DOI":"10.1136\/amiajnl-2012-001065","article-title":"Chart biopsy: an emerging medical practice enabled by electronic health records and its impacts on emergency department\u2013inpatient admission handoffs","volume":"20","author":"Hilligoss","year":"2013","journal-title":"J Am Med Inform Assoc"},{"issue":"2","key":"2020110613055107500_ocy155-B47","doi-asserted-by":"crossref","first-page":"430","DOI":"10.4338\/ACI-2014-01-RA-0003","article-title":"What do physicians read (and ignore) in electronic progress notes?","volume":"5","author":"Brown","year":"2014","journal-title":"Appl Clin Inform"},{"issue":"01","key":"2020110613055107500_ocy155-B48","doi-asserted-by":"crossref","first-page":"169","DOI":"10.1055\/s-0037-1619454","article-title":"Determining primary care physician information needs to inform ambulatory visit note display","volume":"05","author":"Clarke","year":"2014","journal-title":"Appl Clin Inform"},{"key":"2020110613055107500_ocy155-B49","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1016\/j.jbi.2016.10.004","article-title":"Development of a cognitive framework of patient record summary review in the formative phase of user-centered design","volume":"64","author":"Horsky","year":"2016","journal-title":"J Biomed Inform"},{"key":"2020110613055107500_ocy155-B50","author":"Miles"},{"issue":"5\u20136","key":"2020110613055107500_ocy155-B51","first-page":"778","article-title":"Differences in the handover process and perception between nurses and residents in a critical care setting","volume":"24","author":"Mukhopadhyay","journal-title":"J Clin Nurs"},{"issue":"11","key":"2020110613055107500_ocy155-B52","doi-asserted-by":"crossref","first-page":"487","DOI":"10.1097\/CIN.0000000000000187","article-title":"Nurses\u2019 own recordkeeping: the nursing minimum data set revisited","volume":"33","author":"Halloran","year":"2015","journal-title":"Comput Inform Nurs"},{"issue":"6","key":"2020110613055107500_ocy155-B53","doi-asserted-by":"crossref","first-page":"806","DOI":"10.1197\/jamia.M3037","article-title":"Evaluation of a method to identify and categorize section headers in clinical documents","volume":"16","author":"Denny","year":"2009","journal-title":"J Am Med Inform Assoc"},{"issue":"1","key":"2020110613055107500_ocy155-B54","doi-asserted-by":"crossref","first-page":"149","DOI":"10.1016\/j.jpedsurg.2016.10.040","article-title":"Automated data extraction: merging clinical care with real-time cohort-specific research and quality improvement data","volume":"52","author":"Hebal","year":"2017","journal-title":"J Pediatr Surg"},{"issue":"sp","key":"2020110613055107500_ocy155-B55","doi-asserted-by":"crossref","first-page":"102","DOI":"10.12927\/hcq.2010.21974","article-title":"Optimizing physician handover through the creation of a comprehensive minimum data set","volume":"13","author":"Mistry","year":"2010","journal-title":"Healthc Q"},{"issue":"05","key":"2020110613055107500_ocy155-B56","doi-asserted-by":"crossref","first-page":"412","DOI":"10.3414\/ME15-02-0001","article-title":"Cognitive maps to visualise clinical cases in handovers: design, implementation, usability, and attractiveness testing","volume":"54","author":"Flemming","year":"2015","journal-title":"Methods Inf Med"},{"issue":"6","key":"2020110613055107500_ocy155-B57","doi-asserted-by":"crossref","first-page":"691","DOI":"10.3122\/jabfm.2017.06.170028","article-title":"Dynamic electronic health record note prototype: seeing more by showing less","volume":"30","author":"Belden","year":"2017","journal-title":"J Am Board Fam Med"},{"issue":"03","key":"2020110613055107500_ocy155-B58","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1055\/s-0038-1635274","article-title":"Functional characteristics of a computerized medical record","volume":"19","author":"Hammond","year":"1980","journal-title":"Methods Inf Med"},{"issue":"11","key":"2020110613055107500_ocy155-B59","doi-asserted-by":"crossref","first-page":"1300","DOI":"10.1177\/0009922818774341","article-title":"National survey of pediatric care providers: assessing time and impact of coding and documentation in physician practice","volume":"57","author":"Arora","year":"2018","journal-title":"Clin Pediatr (Phila)"},{"issue":"5","key":"2020110613055107500_ocy155-B60","doi-asserted-by":"crossref","first-page":"924","DOI":"10.1093\/jamia\/ocv181","article-title":"The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting","volume":"23","author":"Her","year":"2016","journal-title":"J Am Med Inform Assoc"},{"key":"2020110613055107500_ocy155-B61","article-title":"To combat physician burnout and improve care, fix the electronic health record","author":"Wachter","year":"2018","journal-title":"Harvard Business Review"},{"key":"2020110613055107500_ocy155-B62","author":"Xiong","year":"2016"},{"issue":"2","key":"2020110613055107500_ocy155-B63","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1136\/jamia.2010.007237","article-title":"Data from clinical notes: a perspective on the tension between structure and flexible documentation","volume":"18","author":"Rosenbloom","year":"2011","journal-title":"J Am Med Inform Assoc"}],"container-title":["Journal of the American Medical Informatics Association"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/academic.oup.com\/jamia\/article-pdf\/26\/2\/172\/34151380\/ocy155.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"http:\/\/academic.oup.com\/jamia\/article-pdf\/26\/2\/172\/34151380\/ocy155.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2020,11,14]],"date-time":"2020-11-14T05:20:37Z","timestamp":1605331237000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/jamia\/article\/26\/2\/172\/5255653"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2018,12,20]]},"references-count":63,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2018,12,20]]},"published-print":{"date-parts":[[2019,2,1]]}},"URL":"https:\/\/doi.org\/10.1093\/jamia\/ocy155","relation":{},"ISSN":["1067-5027","1527-974X"],"issn-type":[{"value":"1067-5027","type":"print"},{"value":"1527-974X","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2019,2]]},"published":{"date-parts":[[2018,12,20]]}}}