The impact of structured and standardized documentation on documentation quality: a multicenter, retrospective study
Open accessAbstract
The reuse of healthcare data for various purposes will become increasingly important in the future. To enable the reuse of clinical data, structured and standardized documentation is conditional. However, the primary purpose of clinical documentation is to support high-quality patient care. Therefore, this study investigated the effect of increased structured and standardized documentation on the quality of notes in the Electronic Health Record. A multicenter, retrospective design was used to assess the difference in note quality between 144 unstructured and 144 structured notes. Independent reviewers measured note quality by scoring the notes with the Qnote instrument. This instrument rates all note elements independently using and results in a grand mean score on a 0–100 scale. The mean quality score for unstructured notes was 64.35 (95% CI 61.30–67.35). Structured and standardized documentation improved the Qnote quality score to 77.2 (95% CI 74.18–80.21), a 12.8 point difference (p < 0.001). Furthermore, results showed that structured notes were significantly longer than unstructured notes. Nevertheless, structured notes were more clear and concise. Structured documentation led to a significant increase in note quality. Moreover, considering the benefits of structured data recording in terms of data reuse, implementing structured and standardized documentation into the EHR is recommended.
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Prior studies on clinical documentation suggest that structured formats improve readability and may be perceived as higher quality.
“Prior studies on clinical documentation suggest that structured formats improve readability and may be perceived as higher quality.27,28”
From Large Language Model–Generated Electronic Consultations: A Blinded Comparative Study of OpenEvidence and Gastroenterologist Electronic Consultations (2026) · cites this paper as [27]
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Balloch, J., Sridharan, S., Oldham, G., Wray, J., Gough, P., Robinson, R., Sebire, N. J., Khalil, S., Asgari, E., Tan, C., et al. (2024) · Future Healthcare Journal · doi:10.1016/j.fhj.2024.100157 · Cited by 107 · see citing works
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Stephenson, C. R., Varayil, J. E., Salonen, B. R., Wight, E. C., Sang, P. D., Ghosh, A. K., Shung, D. L., Croghan, I. T., Schroeder, D. R., & Hurt, R. T. (2026) · Mayo Clinic Proceedings: Digital Health · doi:10.1016/j.mcpdig.2026.100404
- Authors
- Ebbers, T., Kool, R. B., Smeele, L. E., Dirven, R., den Besten, C. A., Karssemakers, L. H. E., Verhoeven, T., Herruer, J. M., van den Broek, G. B., & Takes, R. P.
- Affiliations
- Radboud University Medical Center (NL)
- The Netherlands Cancer Institute (NL)
- Corresponding author
- Ebbers, Tom
- ORCID
- Venue
- Journal of Medical Systems
- Published
- 2022-05-27
- Volume
- 46
- Issue
- 7
- Pages
- 46-46
- ISSN
- 0148-5598 (ISSN-L)
- 1573-689X
- PMC
- PMC9135789
- OpenAlex
- W4281989098
- Cited by
- 144
- References
- 3
- Citations by year
- 2026: 49 · 2025: 55 · 2024: 30 · 2023: 10
- FWCI
- 17.77
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Journal of Medical Systems (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Pure Amsterdam UMC (publishedVersion, cc-by)
- Radboud Repository (Radboud University) (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Radboud Repository (Radboud University) (submittedVersion, other-oa)
- Topics
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Nursing › Issues, ethics and legal aspects › Nursing Diagnosis and Documentation
- Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
- Keywords
- standardized documentation, electronic health records, clinical data reuse
- MeSH terms
- Documentation, Humans, Quality of Health Care, Retrospective Studies, Electronic Health Records
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