Barriers and Facilitators to Electronic Health Record Documentation Compliance in Multidisciplinary Hospital Settings: A Scoping Review

Introduction

Electronic health records (EHRs) are widely implemented to improve continuity of care, information access, and care coordination across clinical disciplines.^1,2 In acute hospital settings, patient care depends on timely and coordinated contributions from nurses, physicians, pharmacists, and allied health professionals. When documentation is incomplete, delayed, inconsistently structured, or difficult to retrieve, the clinical record may become fragmented, limiting shared understanding of patient status, care plans, and clinical risks across the multidisciplinary team.³

In this review, documentation compliance refers to the extent to which required clinical documentation is completed in a timely, complete, structured, and retrievable manner, and can be used by other disciplines to support communication, coordination, and clinical decision-making. This definition includes completion of required documentation fields or templates, but also extends to documentation quality, retrievability, and interprofessional usability when these aspects influence multidisciplinary information flow.

EHRs may support documentation compliance by enabling shared access to patient information, co-located documentation, structured templates, reminders, alerts, and audit-and-feedback functions.^4,5 However, these systems may also create barriers when documentation workflows are poorly aligned with clinical work. In multidisciplinary acute care, documentation burden, complex interfaces, high screen burden, information overload, fragmented documentation locations, and heterogeneous documentation formats can reduce the timeliness, completeness, and usability of clinical documentation. These problems matter because documentation is not only a legal or administrative record. It is also a communication tool that supports handovers, rounds, care planning, and shared decision-making across professional groups.^3,5,6 These problems matter because documentation is not only a legal or administrative record. It also functions as a communication tool for handovers, rounds, care planning, and shared decision-making across professional groups.

Automation and emerging digital tools further complicate documentation compliance. Features such as copy-forward, copy-paste, checkbox-driven templates, auto-populated fields, reminders, and alerts may improve efficiency and standardisation. However, they may also increase the risk of note bloat, inaccurate carryover, reduced critical review, and loss of clinically meaningful detail.^7,8 More recent developments, including AI-assisted documentation and ambient AI scribes, may support documentation by reducing manual entry burden and generating structured clinical notes. However, these tools also shift compliance concerns toward verification, accuracy, governance, and the usability of generated documentation for cross-disciplinary care.⁹

From a sociotechnical perspective, EHR documentation compliance is shaped by the interaction between technology design, clinician behaviour, workflow demands, organisational standards, training, and governance.^6,10 Prior studies have identified barriers and facilitators to digital health technology use, including usability, workflow fit, training adequacy, and management support.^10,11 However, much of the evidence remains profession-specific or focuses on EHR use more broadly. Fewer studies have specifically examined documentation compliance as a multidisciplinary information problem in acute hospital workflows, where the value of documentation depends not only on whether it is completed, but also on whether it is accurate, retrievable, meaningful, and usable by other professional groups.

The novelty of this review lies in its focus on EHR documentation compliance as a multidisciplinary information-use issue in acute hospital settings. Rather than examining EHR use or documentation burden in general, this review emphasizes how documentation practices affect the ability of different professional groups to access, interpret, and use clinical information for communication, care coordination, and decision-making. This focus is important because documentation compliance in multidisciplinary care depends not only on completion of required fields, but also on documentation quality, retrievability, visibility, and interprofessional usability.

Therefore, this scoping review, guided by the Joanna Briggs Institute methodology, aims to map barriers and facilitators influencing EHR documentation compliance in multidisciplinary acute care hospital settings. By synthesising the evidence through a sociotechnical lens, this review seeks to clarify how technological, individual and behavioural, and organisational and environmental factors shape documentation practices, interprofessional information flow, and coordinated patient care.

Methods

Study Design and Methodology

This study was conducted as a scoping review in accordance with the Joanna Briggs Institute methodological guidance for scoping reviews.¹² The review methods were specified before study selection to enhance transparency and reproducibility. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines.¹³

A scoping review approach was selected because the review aimed to map the breadth, characteristics, and gaps of evidence on barriers and facilitators influencing EHR documentation compliance in multidisciplinary acute care hospital settings. This approach was appropriate given the heterogeneity of study designs, clinical settings, documentation outcomes, and implementation contexts across the available literature.¹²

Findings were synthesized using a sociotechnical systems perspective. This perspective allowed the review to examine how technological factors, individual and behavioral factors, and organizational and environmental factors interact to shape documentation practices, documentation compliance, and multidisciplinary information flow.⁶ Ethical approval was not required because this review used publicly available published literature and did not involve direct interaction with human participants.

Eligibility Criteria

Eligibility criteria were developed using the Population, Concept, and Context framework, as recommended by the Joanna Briggs Institute for scoping reviews. The framework was used to ensure that included studies aligned with the review objective and focused on EHR documentation compliance within multidisciplinary acute care hospital workflows.

• Population: This review included studies involving healthcare professionals who provide direct clinical care and document at the point of care in hospital settings. Eligible professionals included nurses, physicians, pharmacists, and allied health professionals, such as physiotherapists, occupational therapists, dietitians, speech therapists, and social workers. Studies focusing exclusively on non-clinical personnel, such as administrative staff or IT technicians, or students were excluded. Studies were eligible if they involved multidisciplinary teams or focused on a single profession but examined documentation practices occurring within, or affecting, multidisciplinary hospital workflows, such as information sharing, retrieval, or use by other disciplines.
• Concept: Included studies were required to report barriers and/or facilitators influencing EHR or EMR documentation compliance. In this review, documentation compliance was defined broadly and included timeliness, completeness, adherence to required documentation fields or templates, documentation quality, structured data capture, retrievability, and relevance to multidisciplinary information sharing and clinical decision-making. Studies focused solely on technical architecture, programming algorithms, hardware evaluation, or cost evaluation were excluded unless they were directly linked to clinicians’ documentation behaviours, adherence, or documentation workflow.
• Context: The review was limited to acute care hospital settings, including inpatient wards, emergency departments, intensive care units, and hospital-based outpatient departments or clinics integrated within acute care hospitals. Studies conducted in primary care, long-term care facilities, rehabilitation facilities, nursing homes, or community settings were excluded.
• Types of Evidence: Only primary empirical studies with quantitative, qualitative, or mixed-methods designs published as full-text journal articles were included. Reviews, editorials, opinion papers, protocols, dissertations, conference abstracts, and non-full-text publications were excluded.
• Search Limits:: No date restrictions were applied. Searches covered records from database inception to 13 April 2026. The search was limited to English-language publications because of feasibility constraints.

Search Strategy

A revised search strategy was developed to improve the sensitivity, transparency, and reproducibility of this scoping review. Searches were conducted in PubMed, ScienceDirect, and selected databases accessed through the EBSCOhost platform. Because EBSCOhost is a search platform rather than a single database, the specific databases searched through EBSCOhost were identified as eBook Collection (EBSCOhost), Literary Reference Source, and Middle Eastern & Central Asian Studies. The search covered records from database inception to 13 April 2026, with no date restriction.

The search strategy was guided by the Population–Concept–Context framework. The population block included multidisciplinary healthcare professionals involved in hospital-based clinical documentation, including nurses, physicians, pharmacists, allied health professionals, and other clinical users. The concept block focused on EHR or EMR documentation compliance, including documentation completion, timeliness, completeness, documentation quality, structured data capture, retrievability, adherence to documentation workflows, and barriers or facilitators affecting documentation practices. The context block included acute care, inpatient, emergency, intensive care, and other hospital-based clinical settings.

To improve search sensitivity, key terms were not limited to title-only searching. Where supported by each database, search terms were applied across title, abstract, keyword, subject heading, MeSH terms, or other broader searchable fields. Controlled vocabulary terms, including Medical Subject Headings in PubMed, were combined with free-text keywords related to electronic health records, electronic medical records, clinical documentation, documentation compliance, documentation adherence, documentation completeness, documentation quality, documentation burden, usability, workflow, implementation, barriers, facilitators, multidisciplinary care, interprofessional care, and hospital settings.

Synonyms within each concept were combined using OR, and the main concept blocks were combined using AND. The search strategy was adapted to the indexing structure, searchable fields, and technical requirements of each database. For ScienceDirect, the search syntax was revised to include the core PCC concepts: EHR or EMR terms, clinical documentation and documentation compliance terms, multidisciplinary or interprofessional terms, and acute hospital context terms. The ScienceDirect string was simplified where necessary to comply with the platform’s Boolean connector limits while retaining the key concepts needed to identify relevant studies.

Searches were limited to English-language publications. Eligibility for primary empirical research and hospital-based clinical relevance was assessed during title and abstract screening and full-text review. All retrieved records were exported to Mendeley for deduplication before screening. The complete database-specific search strings, searched fields, search limits, search dates, and database details are provided in Supplementary File 1.

Study Selection

The study selection process was conducted systematically to enhance transparency and minimize selection bias. All search results from PubMed, ScienceDirect, and selected databases accessed through the EBSCOhost platform were exported to Mendeley reference management software. Duplicate records were removed using automated deduplication and manual verification.

After deduplication, two reviewers (PBS and MAA) independently screened titles and abstracts based on the PCC eligibility criteria. Articles considered potentially relevant, or articles whose eligibility could not be determined from the title and abstract alone, were retrieved for full-text review. The same two reviewers independently assessed the full texts against the inclusion and exclusion criteria.

Disagreements at any stage were resolved through discussion until consensus was reached. If consensus could not be achieved, a third reviewer (MK) adjudicated the final decision. The complete selection process, including reasons for full-text exclusion, was documented and is presented in the PRISMA-ScR flow diagram.

Data Extraction/Data Charting

Data were extracted using a structured data charting approach in accordance with Joanna Briggs Institute guidance for scoping reviews. A standardized data charting form was developed by the review team to align with the review objectives. The form was pilot-tested on three included studies to ensure consistency of interpretation and was refined before full data extraction.

Charted data included three main categories: bibliometric and methodological characteristics; context and system characteristics; and key findings. Key findings included documentation compliance measures, reported barriers and facilitators, interventions or implementation strategies where applicable, and implications for multidisciplinary workflows and management.

Data charting was conducted independently by two reviewers (PBS and MAA). Disagreements were resolved through discussion and consensus. When consensus could not be reached, a third reviewer (MK) adjudicated. The charted data informed Tables 1–3, including the summary of study characteristics, barriers and facilitators, and multidisciplinary impacts with managerial implications.

Table 1 Characteristics of Included Studies

Table 2 Barriers and Facilitators Influencing EHR Documentation Compliance

Table 3 Multidisciplinary Impact and Managerial Implication

Data Synthesis

Extracted data were synthesized using a descriptive thematic approach to accommodate heterogeneity across qualitative, quantitative, and mixed-methods studies. Therefore, no meta-analysis was conducted. Reported barriers, facilitators, and intervention or implementation components were first summarized and coded. Coding was conducted independently by two reviewers (PBS and MAA) and refined iteratively through constant comparison across studies.

Discrepancies in coding or domain assignment were resolved through discussion and consensus. When consensus could not be reached, a third reviewer (MK) adjudicated. Quantitative outcomes, such as audit-based compliance rates or intention-to-use scores, were synthesized descriptively and integrated with qualitative findings without statistical pooling.

Guided by a sociotechnical systems perspective, the codes were organized into three overarching domains: technological factors, individual and behavioral factors, and organizational and environmental factors. Technological factors included EHR usability and performance, interface design, navigation burden, system stability, interoperability, and information architecture affecting the availability and retrievability of documentation. Individual and behavioral factors included clinician beliefs, attitudes toward EHR use, trust in digital information, workarounds, reliance on automation features, and documentation behaviors affecting timeliness, completeness, and information quality. Organizational and environmental factors included workload, time pressure, staffing and turnover, access to documentation resources, training, communication during system changes, leadership practices, and local norms shaping interprofessional documentation use.

Findings related to multidisciplinary workflows, including cross-disciplinary information sharing, information retrieval, rounds, handover communication, and care coordination, were charted alongside compliance-related outcomes. This approach allowed the synthesis to show how sociotechnical conditions influenced both documentation practices and team-based care.

Result

Study Selection

Through the revised search of PubMed, ScienceDirect, and selected databases accessed through the EBSCOhost platform, conducted up to 13 April 2026, a total of 608 records were identified: PubMed (n = 154), EBSCOhost platform databases (n = 172), and ScienceDirect (n = 282). All records were exported to Mendeley for deduplication, and 8 duplicate records were removed. The remaining 600 records were screened by title and abstract. During title and abstract screening, 498 records were excluded because they were not relevant to the review question, were not primary empirical studies, did not address EHR/EMR documentation compliance or related barriers and facilitators, or were not conducted in eligible hospital-based clinical settings.

A total of 102 full-text articles were assessed for eligibility. Of these, 80 articles were excluded for the following reasons: not conducted in an eligible acute or hospital-based clinical setting (n = 21); not addressing EHR/EMR documentation compliance, documentation quality, completeness, timeliness, or related barriers and facilitators (n = 24); not primary empirical research, including reviews, commentaries, protocols, or editorials (n = 13); wrong population or not aligned with eligible clinical users or multidisciplinary hospital workflows (n = 12); insufficient focus on documentation-related outcomes or implementation factors (n = 7); and language or full-text accessibility constraints (n = 3). Ultimately, 22 studies met the inclusion criteria and were included in the data charting and thematic synthesis. The selection process is presented in the PRISMA-ScR flow diagram (Figure 1).

Figure 1 PRISMA-ScR flow diagram of the study selection process. *EBSCOhost refers to the search platform. The specific EBSCOhost databases searched were eBook Collection (EBSCOhost), Literary Reference Source, and Middle Eastern & Central Asian Studies.

Study Characteristics

The 22 included studies were published between 2008 and 2026. Most studies were conducted in the United States (n = 14), followed by Sweden (n = 3), Australia (n = 2), Singapore (n = 1), China (n = 1), and Indonesia (n = 1). The studies covered diverse hospital-based clinical settings, including intensive care units, emergency departments, oncology services, stroke care units, pediatric inpatient units, neonatal intensive care units, burn units, medical-surgical wards, allied health services, and multidisciplinary acute care environments.

The included studies used varied methodological approaches. Several studies applied qualitative designs, including ethnographic observation, phenomenology, interviews, focus groups, and scenario-based user testing. Other studies used quality improvement designs, pre-post evaluations, interrupted time-series analysis, retrospective cohort analysis, cross-sectional surveys, mixed-methods approaches, and prospective controlled designs. This methodological diversity reflects the scoping purpose of the review and the implementation-focused nature of the evidence base.

The reviewed digital systems also varied considerably. Some studies examined mature EHR or EMR systems in routine use, while others evaluated early post-implementation systems, pre-implementation perceptions, hybrid paper-electronic workflows, nursing information systems, standardized electronic templates, EHR-integrated reminders, dashboards, automated quality-control modules, and specialty-specific documentation tools. Common documentation targets included vital signs, medication reconciliation, nursing documentation, care plans, handoff documentation, oncology staging, advance care planning, goals-of-care notes, central venous catheter management, burn documentation, and registry-ready structured clinical data.

Across the studies, EHR documentation compliance was operationalized in different ways, including timely completion of required documentation, use of standardized templates, completeness of structured data fields, accuracy of recorded clinical information, documentation accessibility and retrievability, adherence to electronic documentation workflows, and audit-based documentation performance. This variation shows that documentation compliance in multidisciplinary hospital settings extends beyond record completion and also includes documentation quality, structure, visibility, retrievability, and usability for interprofessional care.

Thematic Synthesis of Findings

Based on data extraction and thematic analysis, barriers and facilitators to EHR documentation compliance among multidisciplinary teams were organized into three primary domains: technological factors, individual and behavioral factors, and organizational and environmental factors. These domains are visually summarized in Figure 2 and presented in detail in Table 2.

Figure 2 Thematic map of barriers and facilitators influencing EHR documentation compliance in multidisciplinary hospital settings. The map summarizes three interconnected sociotechnical domains: technological factors, individual and behavioural factors, and organisational and environmental factors.

Technological Factors

Technological factors were consistently reported as key determinants of EHR documentation compliance and multidisciplinary information flow. The main barriers involved system usability, access, interoperability, documentation structure, and information architecture.

Usability and system performance problems were frequently identified. These included slow or unstable system performance, freezing or downtime, high screen burden, limited computer access, cumbersome hardware, multiple logins, and automatic timeouts that disrupted point-of-care documentation.^6,14,33 In pre-implementation settings, perceived system complexity and ease-of-use concerns were also associated with lower intention to use electronic documentation tools.¹⁹

Fragmented documentation architecture was another recurrent barrier. Several studies reported that clinically important information was distributed across multiple EHR locations, hybrid paper-electronic sources, or documents outside the main patient record. This fragmentation reduced the visibility and retrievability of information needed for handovers, rounds, and collaborative decision-making.^16,26,27,34 Interoperability gaps also created duplication and double handling when EHR systems were not well integrated with pharmacy software, registry requirements, nursing notes, physician summaries, or other clinical modules.^6,34

Structured documentation had both benefits and limitations. Templates, dropdown menus, checkboxes, smart phrases, and standardized note formats supported consistency, completeness, and auditability. However, limited structured options could restrict clinically relevant detail, encourage free-text workarounds, increase documentation burden, and reduce the usefulness of notes across professions.^{14,17,22,23,30,33} In stroke care, documentation redundancy persisted when staff lacked a clear overview of where information should be recorded in the EHR.¹⁵

Several technological facilitators supported documentation compliance. These included workflow-aligned templates, standardized note structures, reminders, alerts, tasking functions, embedded advisories, smart phrases, dashboards, auto-populated fields, mobile access, device integration, and automated quality-control systems.^{14,23,24,27–29,31,32} For example, oncology staging compliance improved through EHR-triggered staging forms, tracking functions, best-practice advisories, and automated in-basket reminders.²⁸ Burn documentation was supported by unit-specific templates, autototaling, and pop-up alerts.²³ Handoff documentation improved through an EHR-based I-PASS tool with dashboard monitoring, update cues, mobile access, and single-view handoff access.³¹ ICU documentation quality improved through automated quality-control functions, real-time data capture, monitor and ventilator integration, medication scanning, alerts, and reminders.³²

However, improved technical access did not automatically improve interdisciplinary communication. One evaluation found that access to other clinicians’ notes improved satisfaction and information availability, but did not substantially increase interdisciplinary communication without supporting workflow, training, and implementation strategies.¹⁸ Overall, the technological findings showed that documentation compliance was influenced by the usability, integration, workflow alignment, visibility, and retrievability of EHR documentation tools across professional groups.

Individual/Behavioral Factors

Individual and behavioral factors described how clinicians accepted, produced, verified, and used EHR documentation in daily practice. The main barriers involved variable adoption readiness, trust in digital information, workaround behaviors, selective use of documentation, and over-reliance on structured or convenience features.

Clinician beliefs and experience influenced documentation behavior. In a hospital-wide oncology intervention, greater years of provider experience were associated with lower timely staging compliance, suggesting that sustained adherence may vary by clinician tenure.²⁸ In a pre-implementation study of an electronic clinical measurement record, intention to use was influenced by performance expectancy, effort expectancy, and social influence. During digital transition, some clinicians were hesitant to rely only on digital records and used paper records or peer confirmation as additional sources of truth.⁶ Similar trust and reliability concerns were also reported when clinicians needed to verify automated, structured, or system-generated information before using it for care decisions.^29,33

Workaround behaviors were common when EHR documentation did not fit clinical workflow or information needs. Nurses used informal paper notes, “scraps,” and transcription practices to manage handoffs and information flow when documentation was difficult to retrieve or inconsistently recorded.¹⁶ Other studies reported continued use of email, progress notes, narrative documentation, abbreviations, or non-standard documentation habits when structured EHR tools were perceived as redundant, incomplete, or poorly aligned with clinical practice.^31,34

Behavioral risks linked to structured documentation and convenience features were also identified. Checkbox- and dropdown-driven documentation, copy-paste, and copy-forward functions could reduce critical review and documentation accuracy when clinicians used them without reassessing the current patient situation.^14,35 Structured fields could also limit clinically meaningful detail when available options did not reflect patient-specific context.^22,33 At the interprofessional level, clinicians did not always use documentation to build a holistic understanding of the patient. Allied health notes, for example, were often read selectively to answer profession-specific questions rather than to support broader shared understanding.²²

Facilitators in this domain focused on improving perceived usefulness, ease of use, accountability, and the visible value of documentation. Positive performance expectancy, effort expectancy, and social influence supported readiness to use electronic documentation systems.¹⁹ Clinician-facing feedback, peer comparison, reminders, champions, and one-to-one coaching helped reinforce documentation behaviors by showing how documentation supported care quality, safety metrics, handoff reliability, and team communication.^18,28,31 Overall, the individual and behavioral findings showed that documentation compliance was shaped not only by clinicians’ willingness to complete required fields, but also by how they trusted, verified, interpreted, and used documented information across professional boundaries.

Organizational/Environmental Factors

Organizational and environmental factors shaped whether clinicians could document as intended and whether documentation supported multidisciplinary coordination. The main barriers involved workload pressure, interruptions, limited documentation resources, inconsistent standards, staff turnover, weak implementation communication, and documentation practices that occurred outside the EHR.

Several studies reported structural pressures that increased documentation burden or disrupted timely documentation. These included high documentation time demands, interruptions, constrained workstation access, limited computer availability, system downtime, and inefficient information flow.^6,14,16,33 These conditions reduced clinicians’ ability to document at the point of care and contributed to delayed entry, paper workarounds, or duplicated documentation.

Implementation-stage factors were also important. Staff turnover, new staff onboarding, system upgrades, inconsistent communication about EHR changes, and variability in documentation standards across units affected sustained compliance.^15,23,35 In several implementation studies, repeated education, ongoing monitoring, and clear communication were needed to maintain documentation adherence after system rollout or workflow redesign.^23,24,27,31

Organizational and sociocultural dynamics also influenced how documentation was used across professions. Interprofessional communication was often limited, undocumented, or conducted outside the formal record.^16,26 In CVC management, clinically relevant information was distributed across paper and electronic sources, while oral communication helped clinicians integrate the clinical picture during rounds and collaborative decision-making.²⁶ Similarly, improved access to other clinicians’ notes did not necessarily increase interdisciplinary communication without workflow-aligned practices, shared expectations, and implementation support.³⁵ In handoff documentation, some clinicians continued to rely on email, progress notes, or local habits when standardized EHR tools were not fully embedded into routine practice.³¹

Facilitators in this domain were mainly managerial and governance-related. These included structured audit and feedback, transparent performance reporting, leadership support, stakeholder engagement, clinician-IT collaboration, training infrastructure, service champions, and routine monitoring.^{23,28,29,31,32} Examples included named compliance reporting and automated reminders for oncology staging documentation, clinician-IT co-design and audit processes in burn documentation, dashboard monitoring and mandatory training for handoff documentation, and automated quality-control governance for ICU nursing documentation.^23,28,31,32

Overall, the organizational and environmental findings showed that sustainable EHR documentation compliance depends on more than technical system availability. It also requires clear documentation standards, continuous training, workflow governance, feedback loops, leadership support, and routines that make documentation visible and useful across professional groups.

Multidisciplinary Impact and Managerial Implications

Across the included studies, EHR-enabled documentation shaped multidisciplinary care by influencing how clinicians found, interpreted, and used information documented by other professions. Although electronic systems improved access to clinical information and supported some point-of-care efficiencies, access alone did not consistently improve interdisciplinary communication or shared situational awareness. One evaluation reported that access to other clinicians’ notes improved satisfaction and information availability, but did not substantially increase interdisciplinary team communication.¹⁸

Several studies showed that fragmented documentation continued to drive reliance on oral communication. This was especially evident when clinically important information was distributed across multiple EHR locations, hybrid paper-electronic sources, or documents outside the formal patient record.^16,26 In CVC management, for example, collaborative decision-making depended heavily on oral exchange because relevant information was spread across paper and electronic sources.²⁶ Discipline-specific differences also affected multidisciplinary use. During digital hospital transition, EHR workflows were more aligned with medical and nursing activities than with allied health and pharmacy workflows, while rapid-login access, workstation placement, and cumbersome workstations shaped how different professional groups engaged with digital documentation at the point of care.⁶ The interpretability of documentation also mattered. Allied health notes were often used selectively to answer profession-specific questions rather than to support a holistic understanding of the patient.²²

Recent implementation studies further showed that multidisciplinary impact improved when EHR documentation tools were embedded into routine team workflows. Centralized goals-of-care documentation improved access to clinically important information across primary teams and specialty palliative care.²⁹ Standardized I-PASS handoff documentation improved shared access to handoff information across inpatient services.³¹ Automated quality-control functions improved the reliability of ICU nursing documentation, supporting safer information use by the clinical team.³² Registry-oriented documentation also showed the need for stronger coordination between clinicians, nurses, medical records staff, and IT teams to improve structured data completeness and interprofessional data use.³⁴

From a managerial perspective, the evidence suggests that sustainable documentation compliance and meaningful multidisciplinary use require sociotechnical governance, not only system deployment. Effective approaches combined workflow-aligned system design, clear documentation standards, continuous training, clinician-IT collaboration, leadership support, and audit-feedback mechanisms. Examples included clinician-IT co-design and routine audits to maintain burn documentation compliance, structured reporting and automated reminders to improve oncology staging documentation, leadership engagement and centralized documentation tools for goals-of-care documentation, dashboard monitoring and mandatory training for handoff documentation, and automated quality-control governance for ICU documentation.^{23,28,29,31,32}

Overall, the findings indicate that EHR documentation supports multidisciplinary care when it is visible, retrievable, interpretable, and embedded in shared clinical workflows. A condensed summary of the reported multidisciplinary impacts and actionable managerial implications across studies is presented in Table 3.

Discussion

Principal Findings

This scoping review mapped empirical evidence on barriers and facilitators influencing EHR documentation compliance in multidisciplinary acute care hospital settings. The findings show that documentation compliance is not determined only by individual clinician behavior or technical system availability. Instead, it is shaped by sociotechnical interactions among EHR design, system performance, clinician trust and documentation behavior, workflow demands, organizational standards, training, and governance.

This review contributes to the literature by framing EHR documentation compliance as a multidisciplinary information-use problem, not merely as a record completion or technology adoption issue. This framing highlights the need to evaluate documentation by its timeliness, completeness, structure, retrievability, accuracy, and usability across professional boundaries.

Across the included studies, poor workflow fit emerged as a central issue. EHR systems supported documentation when they improved access, structure, visibility, and auditability of clinical information. However, they also created barriers when documentation was fragmented across multiple locations, difficult to retrieve, poorly aligned with clinical workflow, or dependent on duplicate entry. These conditions can delay documentation, reduce completeness, weaken information quality, and limit the usefulness of documentation for handovers, rounds, care planning, and multidisciplinary decision-making.

Technology and Workflow Fit as Foundational Determinants

Technology and workflow fit emerged as foundational determinants of EHR documentation compliance. Across studies, the most consistent technological barriers involved poor usability, access friction, fragmented information architecture, and limited alignment between EHR functions and real clinical workflows. These barriers affected whether clinicians could document at the point of care, retrieve relevant information, and use documentation for multidisciplinary decision-making.

Usability problems created direct barriers to timely and complete documentation. Reported issues included slow system performance, downtime, limited computer availability, high screen burden, cumbersome workstations, multiple logins, automatic timeouts, and interoperability gaps that required duplicate handling of information.^6,14,33 These findings show how EHR systems can diverge from work-as-done, prompting clinicians to delay documentation, duplicate information, or rely on parallel paper artefacts to maintain clinical workflow.^6,16 External evidence also shows that documentation burden and fragmented systems can consume clinical time and contribute to dissatisfaction and inefficiency.^36,37

Information fragmentation was another recurring challenge. Several studies showed that clinically important information was distributed across multiple EHR locations, hybrid paper-electronic sources, or documents outside the formal patient record. This reduced team-level visibility and made it harder for clinicians to retrieve an integrated picture of patient status, care plans, and clinical risks.^16,26,27,34 In CVC management, for example, information needed for collaborative decision-making was dispersed across paper and electronic sources, requiring oral communication to integrate the clinical picture.²⁶

These findings suggest that documentation compliance should not be interpreted only as completion of required fields. In multidisciplinary acute care, compliance also depends on whether documentation functions as a reliable, retrievable, and usable communication infrastructure. EHR tools are more likely to support compliance when they reduce workflow friction, centralize important information, improve interoperability, and make documentation visible across professional groups.

Behavioural Risks and Trust

Beyond workflow friction, several studies identified behavioral mechanisms that may weaken documentation quality and cross-disciplinary usefulness. Structured documentation and convenience features, such as checkboxes, drop-down menus, copy-paste, and copy-forward functions, can support faster documentation. However, they may also reduce critical review, encourage inaccurate carryover, and limit the capture of clinically meaningful patient-specific details when structured options are insufficient.^14,17,33

These risks align with broader concerns about automation complacency and documentation inflation. When clinicians can easily replicate or template information, they may pay less attention to whether the documented content still reflects the current clinical situation.^8,38 In multidisciplinary care, this issue is important because other clinicians may rely on previously documented information for handovers, rounds, care planning, and decision-making.

Documentation effectiveness also depends on how clinicians read and interpret information produced by other professions. Allied health notes, for example, were often read selectively to answer profession-specific questions rather than to build a holistic understanding of the patient.²² This selective use may limit shared situational awareness, even when documentation is technically accessible.

Trust in digital information was another important behavioral factor. During digital transition, some clinicians hesitated to rely only on digital records and used paper sources or peer confirmation to validate clinical information. Alert fatigue also contributed to rapid dismissal of decision-support prompts.⁶ These findings suggest that documentation compliance is shaped not only by whether clinicians complete required documentation, but also by how they trust, verify, interpret, and reuse information within the EHR environment.

Governance and Sustainability

Organizational governance was central to sustaining EHR documentation compliance. Several studies showed that documentation adherence could decline when implementation relied only on initial training or system deployment. Staff turnover, onboarding of new clinicians, system upgrades, unclear communication, and inconsistent documentation standards across units contributed to variability in documentation practices.^15,18,23 In specialty documentation conversion, high nursing turnover and the arrival of new staff were associated with periodic compliance declines, requiring repeated education and ongoing audit processes.²³ In the Nursing Information System evaluation, nurses reported confusion related to system upgrades, inadequate communication, and inconsistent standards across units.¹⁷ Similarly, in the implementation of evidence-based standardized care plans for stroke care, staff perceived the tool as useful and showed improved guideline knowledge, but documentation time did not decrease and redundancy remained a concern.¹⁵ These findings indicate that standardization must be supported by clear documentation locations, navigation support, communication, and continuous training.

Studies that combined governance mechanisms with EHR-enabled prompts and feedback reported stronger documentation improvements. Oncology staging documentation improved through standardized workflows, automated reminders, audit and reporting infrastructure, and training.²⁸ Handoff documentation improved when the EHR-based I-PASS tool was supported by service champions, dashboard monitoring, mandatory training, and routine feedback.³¹ Goals-of-care documentation also improved through leadership engagement, centralized EHR tools, automated notifications, education, and dashboard feedback. ICU nursing documentation quality improved through automated quality-control rules, real-time reminders, and collaboration between nursing leaders, nurse researchers, and information engineers.³²

Overall, these findings suggest that sustainable documentation compliance requires more than technical tools. It depends on governance routines that maintain clear standards, continuous training, audit and feedback, leadership support, clinician-IT collaboration, and role-specific implementation support. Documentation compliance should therefore be managed as an ongoing clinical and organizational process, not as a one-time system implementation or an individual clinician responsibility.

Access–Communication Gap

A key cross-cutting finding was that improved access to digital documentation did not automatically translate into stronger interdisciplinary communication. Electronic systems could make clinical notes more available, but access alone was insufficient when documentation was fragmented, difficult to interpret, or not embedded in shared team workflows.

One hospital evaluation found that cross-note access improved satisfaction and information availability, but did not substantially increase interdisciplinary communication.¹⁸ Similarly, when documentation was distributed across multiple EHR locations, hybrid paper-electronic sources, or documents outside the formal patient record, teams continued to rely on verbal exchange to integrate the clinical picture.^16,26 In CVC management, oral communication helped clinicians maintain collaborative decision-making when relevant information remained dispersed across paper and electronic sources.

This access–communication gap suggests that multidisciplinary communication requires more than digital availability of notes. It also requires usable summaries, centralized information displays, interoperability, shared documentation standards, training, and accountability for cross-disciplinary documentation use. These findings reinforce that EHR documentation compliance should be evaluated not only by completion or access, but also by whether documentation supports shared understanding and coordinated clinical decision-making across professional groups.

Implications and Evidence Gaps

The findings suggest that EHR documentation compliance in multidisciplinary hospital settings should be approached as a sociotechnical issue rather than as an individual clinician responsibility. Hospitals may strengthen documentation practices by reducing EHR-related friction, aligning documentation tools with clinical workflows, ensuring adequate point-of-care resources, clarifying documentation standards, and using audit-and-feedback mechanisms to make the value of documentation visible for interprofessional coordination and patient safety. These strategies are supported by studies reporting the use of workflow-aligned templates, automated reminders, clinician-IT collaboration, structured training, dashboard monitoring, and audit-feedback mechanisms to improve documentation practices.^{23,24,27,28,31,32}

However, these practical implications should be interpreted cautiously. The available evidence remains limited, heterogeneous, and largely based on qualitative, single-site, or quality-improvement studies. In addition, no formal critical appraisal was conducted, consistent with the purpose of a scoping review. Therefore, these recommendations should be considered evidence-informed considerations rather than definitive conclusions about intervention effectiveness.

Several evidence gaps remain. First, definitions and operational measures of documentation compliance varied across studies. Some studies measured behavioral intention to use electronic documentation systems, while others assessed audit-based compliance, timely completion, structured data completeness, documentation quality, accessibility, retrievability, or qualitative documentation practices.^{19,23,28,32,34} This variation limits comparison across settings and reduces certainty about which intervention components are most influential.

Second, few studies directly measured downstream outcomes such as interprofessional coordination, continuity of care, shared situational awareness, or patient safety. Most studies focused on documentation processes, documentation quality, access to notes, compliance rates, or implementation outcomes rather than direct team-based or patient-level outcomes.^{16,17,22,26,31}

Third, the evidence base was concentrated mainly in high-income settings and included several studies with predominantly nursing samples. This may limit transferability to other professional groups and health system contexts.^{14,16,17,20,26,33} Future studies should use clearer compliance definitions, broader multidisciplinary samples, multi-site and longitudinal designs, and outcome measures that link documentation compliance with team communication, care coordination, and patient safety.

Strengths and Limitations

This scoping review has several strengths. First, the review followed the Joanna Briggs Institute methodological guidance and was reported according to PRISMA-ScR, which strengthened transparency and reproducibility. Second, the Population–Concept–Context framework helped focus the review on EHR documentation compliance within multidisciplinary acute care hospital workflows. Third, the revised search strategy improved search sensitivity by expanding key terms beyond title-only searching and applying them across broader searchable fields where supported by each database. Fourth, the use of a sociotechnical lens allowed the synthesis to capture how technological, individual and behavioral, and organizational and environmental factors interact to shape documentation practices and multidisciplinary information flow.

Several limitations should also be considered when interpreting the findings. First, the search was restricted to PubMed, ScienceDirect, and selected databases accessed through the EBSCOhost platform, as well as to English-language publications. Although these sources were selected to capture health, nursing, and multidisciplinary clinical literature, this restriction may have limited the identification of relevant studies indexed in other databases or published in other languages. Second, although the revised search increased the number of included studies to 22, the evidence base remains limited and was concentrated mainly in high-income countries. This may reduce the transferability of the findings to hospitals with different digital infrastructures, staffing models, documentation policies, and EHR implementation maturity.

Third, qualitative, single-site, and quality-improvement studies predominated. These designs provide valuable insight into real-world documentation practices, workflow barriers, clinician behaviors, and implementation processes. However, they limit the ability to estimate effect sizes, compare interventions, or draw causal conclusions. Fourth, documentation compliance was defined and measured inconsistently across studies, including intention to use, audit-based completion, timeliness, completeness, structured documentation, documentation quality, and qualitative descriptions of documentation practices. This variation reduces comparability across studies and weakens certainty about which barriers, facilitators, or intervention components are most influential.

Fifth, although this review focused on multidisciplinary hospital settings, several studies primarily involved nurses. This may underrepresent profession-specific barriers and facilitators among physicians, pharmacists, and allied health professionals. Finally, consistent with the purpose of a scoping review, no formal critical appraisal of included studies was conducted. Therefore, the conclusions should be interpreted as an evidence map of available literature rather than a graded assessment of evidence strength or intervention effectiveness. Practical recommendations should be applied cautiously and adapted to local workflow, staffing, governance structures, and EHR maturity.

Future Research

Future research should move beyond descriptive accounts of documentation burden toward intervention-focused and outcome-linked studies that clarify what strategies sustainably improve documentation compliance and multidisciplinary communication. First, studies should adopt more consistent definitions and operational measures of documentation compliance (eg, timeliness, completeness, adherence to required structures/templates, and cross-disciplinary retrievability), enabling comparisons across contexts and systems Second, there is a need for multi-site and longitudinal designs evaluating how sociotechnical interventions such as usability redesign, interoperability improvements, centralised summaries/modules, and targeted training affect both documentation outcomes and downstream team-based outcomes (eg, shared situational awareness during rounds, handover quality, coordination of care, and patient safety indicators).

Third, research should explicitly examine profession-specific needs and trade-offs, including how different professional groups author, locate, and interpret documentation created by others, and how these behaviours influence interdisciplinary decision-making. Participatory and co-design approaches that involve nursing, medicine, pharmacy, and allied health clinicians as co-developers are likely to be particularly valuable for aligning digital tools with “work-as-done.” Finally, future studies should evaluate the effectiveness and unintended consequences of automation features (eg, copy-forward, templating, alerts) on information quality and clinical reasoning, as well as the impact of feedback mechanisms (dashboards, audit-and-feedback, and peer comparison approaches) on sustaining documentation behaviours over time.

Conclusion

EHR documentation compliance in multidisciplinary hospital settings is a complex sociotechnical issue shaped by the interaction of technology design, clinician behaviours, and organisational conditions. The most critical barrier identified in this review was poor workflow fit, particularly when EHR systems created navigation burden, access friction, fragmented information locations, and limited team-level visibility of clinically important documentation. These conditions can undermine timely, complete, structured, retrievable, and cross-discipline usable documentation.

The findings also show that improved digital access to other clinicians’ notes does not automatically strengthen interprofessional communication. When documentation is fragmented or difficult to retrieve, teams may continue to rely on oral workarounds to integrate the clinical picture. Therefore, sustainable improvement may require more than system implementation. Hospitals should consider workflow-aligned EHR design, clear documentation standards, continuous and discipline-sensitive training, and audit-and-feedback mechanisms that make the value of documentation visible for quality, safety, and multidisciplinary care coordination.

Because the evidence base was limited, heterogeneous, and not formally appraised, these recommendations should be interpreted as evidence-informed considerations rather than definitive conclusions about intervention effectiveness. They should also be adapted to local workflow, staffing, governance structures, and EHR maturity. By mapping barriers and facilitators through a sociotechnical lens, this review provides a practical evidence map for hospital leaders, clinicians, and digital health implementation teams seeking to improve EHR documentation compliance and strengthen interprofessional information flow in acute care settings.