Optimal approach to standardized documentation in epilepsy clinics: A scoping review

Clear documentation and transfer of information between health care providers is key to ensuring the delivery of high-quality patient care. Our aim was to determine how to optimize and standardize physician documentation in outpatient epilepsy clinics as well as to highlight challenges and barriers to their implementation. We conducted a scoping review of studies implementing standardization and optimization of physician documentation within outpatient epilepsy clinics. The study is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. The following databases were searched from inception to March 2025: MEDLINE, Embase, APA PsycInfo, CINAHL, and Cochrane Library. All abstracts, full texts, and data charting were completed in duplicate. The search yielded 10 268 studies, of which 16 met eligibility criteria. Studies were primarily from the United States (n = 12, 75.0%) and focused on adult practices (n = 9, 56.25%). Studies were quality improvement framework/consensus guideline investigations (n = 9, 56.3%), observational audits/cross-sectional designs (n = 2, 12.5%), and retrospective cohort/chart reviews (n = 2, 12.5%), followed by several mixed-methods development, observational field study, and observational toolkit implementation designs (n = 1, 6.25% each). Most clinical notes were in electronic medical records (n = 14, 87.5%) using free-text fields (n = 4, 25.0%), structured fields (n = 2, 12.5%), or hybrid approaches (n = 7, 43.8%). Common Data Elements included seizure information and treatment counseling information. Outcomes associated with standardized note implementation included reduced epilepsy-related adverse events, better seizure control, and more consistent documentation of pertinent patient information. Highlighted challenges to implementation included workflow disruptions, hesitation to initial uptake, and cost-related barriers such as information technology support. Implementation of standardized documentation was associated with fewer adverse events and better seizure control. Future efforts should prioritize inclusive design, have expanded quality indicators, be easy to use at point of care, and have robust evaluation metrics to optimize their utility for epilepsy care.