Characteristics and Challenges of Clinical Documentation in Self-Organized Fast-Paced Medical Work

Abstract

Clinical documentation is a time-consuming and challenging task, especially in time-critical medical settings. Even with a dedicated scribe person, timely and accurate documentation under time constraints is never easy. In this work, we present a unique type of fast-paced medical team--emergency medical services (EMS)--which has no designated role for documentation while constantly working outside in the field to provide urgent patient care. Through interviews with 13 EMS practitioners, we reveal several interesting and prominent characteristics of EMS documentation practice as well as their associated challenges: EMS practitioners self-organize and collaborate on documentation while in the meantime being both physically and cognitively preoccupied with high-acuity patients, having limited capability to use handheld documentation systems in real-time, and being overwhelmed by strict documentation requirements and regulations. Lastly, we use our findings to discuss both technical and non-technical implications to support timely and collaborative documentation in dynamic medical contexts while accounting for care providers' physical and cognitive constraints in using computing devices.