Table 1 Inclusion and exclusion criteria for abstract and full-text screening stages of the systematic review
Criteria | Included | Excluded |
|---|---|---|
Abstract screening | ||
Study design | Original research: observational, experimental, quasi-experimental | Letters, editorials, comments, book chapters, systematic reviews |
Outcome | EHR documentation | Paper documentation Other studies unrelated to the topic: not looking at EHR nor documentation, animal studies |
Setting | Inpatient or acute/care Single/multi-center | Outpatient, emergency department, clinic |
Intervention | Variety of interventions | No intervention, only reporting on current documentation quality |
Full-text screening | ||
Study design | Original research: observational, experimental, quasi-experimental | Letters, editorials, comments, book chapters, systematic reviews |
Outcome | EHR documentation | Paper documentation Other studies unrelated to the topic: not looking at EHR nor documentation, animal studies |
Setting | Inpatient or acute/care Single/multi-center | Outpatient, emergency department, clinic, family practice offices, minor/day/dental surgeries |
Intervention | Variety of interventions | No intervention, only reporting on current documentation quality |
Document type | Inpatient electronic records (authors contacted if unclear) | EHR implementation on paper-based system (unless study compared paper documentation to at least 2 other arms using electronic documentation) Not explicitly reporting on “inpatient” or “electronic” |
Participants (EHR user) | Nurses, physicians, therapists, diagnostic imaging, pharmacists | Primary care providers (family physicians, general practitioners, etc.), researchers, coders, patients, management |
Outcome | Improving EHR documentation (see Table 2) | Studies using EHR documentation to improve other healthcare service areas (e.g., patient care, healthcare delivery) or improved analytical features within EHR for research purposes. Clinical outcomes as primary or secondary goal |