e.g. mhealth
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Documentation in the electronic health record (EHR) can provide this opportunity. Furthermore, poor documentation can reflect lack of refined CR and has been hypothesized to be linked to diagnostic errors [2-4].
J Med Internet Res 2025;27:e67967
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Furthermore, Levy et al [23] emphasized that health professionals encounter an excessive documentation burden when the usability of the documentation systems fails to adequately support patient care delivery. This highlights the crucial role of systems’ usability and the need to assess their impact on documentation practices.
JMIR Form Res 2025;9:e63902
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documentation scientific response documentation
JMIR AI 2025;4:e55277
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Impact of a Digital Scribe System on Clinical Documentation Time and Quality: Usability Study
In total, 21 medical students with experience in clinical practice and clinical documentation from Leiden University Medical Center consented to participate in our study. All students had a bachelor’s degree in medicine and completed a course in clinical documentation. The students received a compensation of €100 (US $111) for their participation.
Autoscriber is a web-based software application that transcribes and summarizes medical conversations (currently with support for Dutch, English, and German).
JMIR AI 2024;3:e60020
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Other barriers to escalation include delays in documentation, lack of familiarity with the escalation protocol, failure to follow the protocol, and poor communication [10,11].
Digital EWS systems have been proposed as a solution. These systems automatically calculate the EWS based on data input by staff and display relevant information from the escalation protocol.
J Med Internet Res 2024;26:e46691
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Mobile devices may also reduce duplicate documentation [13] and potential documentation errors [17,20] because client data can be documented at the time of its occurrence. In addition, improved decision-making is one of the main advantages [9,20]. Mobile devices continuously provide the latest information on the situation of the clients, which can improve safety and the quality of care [14,18].
J Med Internet Res 2024;26:e46954
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DSPs have indicated that generating required documentation is one of the least rewarding and most onerous aspects of their jobs [16].
JMIR Hum Factors 2024;11:e51612
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Beyond the immediate implications of documentation errors, documentation demands have been identified as a significant contributor to physician burnout [2]. With health care professionals spending an increasing amount of their working hours on paperwork, there is less time and energy left for direct patient care.
J Med Internet Res 2024;26:e54419
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For each ED encounter, there was 1 final physician ED note that aggregated all ED physician documentation. Characteristics of the entire study cohort and variant-specific cohorts are summarized in Table 1. A patient could appear in the cohort more than once if they had multiple ED encounters.
Characteristics of patients at emergency department encounters.
a PCR: polymerase chain reaction.
b ICD-10: International Classification of Diseases, 10th Revision.
J Med Internet Res 2024;26:e53367
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