title: A qualitative analysis evaluating the purposes and practices of clinical documentation.
abstract: OBJECTIVE
  An important challenge for biomedical informatics researchers is determining the best approach for healthcare providers to use when generating clinical notes in settings where electronic health record (EHR) systems are used. The goal of this qualitative study was to explore healthcare providers' and administrators' perceptions about the purpose of clinical documentation and their own documentation practices.
  
  
  METHODS
  We conducted seven focus groups with a total of 46 subjects composed of healthcare providers and administrators to collect knowledge, perceptions and beliefs about documentation from those who generate and review notes, respectively. Data were analyzed using inductive analysis to probe and classify impressions collected from focus group subjects.
  
  
  RESULTS
  We observed that both healthcare providers and administrators believe that documentation serves five primary domains: clinical, administrative, legal, research, education. These purposes are tied closely to the nature of the clinical note as a document shared by multiple stakeholders, which can be a source of tension for all parties who must use the note. Most providers reported using a combination of methods to complete their notes in a timely fashion without compromising patient care. While all administrators reported relying on computer-based documentation tools to review notes, they expressed a desire for a more efficient method of extracting relevant data.
  
  
  CONCLUSIONS
  Although clinical documentation has utility, and is valued highly by its users, the development and successful adoption of a clinical documentation tool largely depends on its ability to be smoothly integrated into the provider's busy workflow, while allowing the provider to generate a note that communicates effectively and efficiently with multiple stakeholders.
authors.affiliation: Department of Biomedical Informatics, Vanderbilt University School of Medicine , Nashville, TN.
authors.forename: Y-X
authors.initials: YX
authors.lastname: Ho
authors.affiliation: Department of Biomedical Informatics, Vanderbilt University School of Medicine , Nashville, TN.
authors.forename: C S
authors.initials: CS
authors.lastname: Gadd
authors.affiliation: Department of Anesthesiology, Vanderbilt University Medical Center , Nashville, TN.
authors.forename: K L
authors.initials: KL
authors.lastname: Kohorst
authors.forename: S T
authors.initials: ST
authors.lastname: Rosenbloom
mesh_terms: D003710:Demography; D004282:Documentation; D006282:Health Personnel; D006801:Humans; D036301:Qualitative Research; D013714:Tennessee
keywords: Clinical documentation and communications; P.H.S.; U.S. Gov’t; electronic health records and systems; personal health records; qualitative methods; support; workflows and human interactions
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