Barriers and Facilitators to Electronic Health Record Documentation Compliance in Multidisciplinary Hospital...

Electronic health records (EHRs) are intended to strengthen continuity of care by enabling shared access to clinical information across disciplines. In this review, documentation compliance refers to completing required clinical documentation in a timely, complete, structured, and retrievable manner to support multidisciplinary information use. However, documentation compliance remains inconsistent in multidisciplinary hospital workflows, limiting its usability for interprofessional coordination and safe decision-making.

To map barriers and facilitators influencing EHR documentation compliance in multidisciplinary acute care hospital settings using a sociotechnical lens.

This scoping review followed Joanna Briggs Institute guidance and was reported according to PRISMA-ScR. A systematic search was conducted in PubMed, ScienceDirect, and selected databases accessed through the EBSCOhost platform from database inception to 13 April 2026. English-language primary empirical studies examining barriers and/or facilitators to EHR documentation compliance in multidisciplinary acute care hospital workflows were included. Two reviewers independently screened studies and charted data. Findings were synthesized using descriptive thematic analysis.

From 608 records, 22 studies met the inclusion criteria. The evidence base was limited and heterogeneous, with qualitative and implementation-focused studies predominating. Technological barriers included poor usability, access friction, fragmented information architecture, and limited team-level visibility. Individual and behavioral barriers included variable trust in digital information, selective documentation use, and reduced critical review linked to structured documentation and convenience functions. Organizational barriers included constrained workstation access, interruptions, inconsistent standards, staff turnover, and insufficient communication or training during system changes. Facilitators included workflow-aligned templates, automation, reminders, alerts, discipline-sensitive training, clinician-IT collaboration, and audit-and-feedback mechanisms.

EHR documentation compliance in multidisciplinary hospitals is shaped by interacting sociotechnical conditions. Evidence-informed improvement should prioritize workflow-aligned design, clear documentation standards, continuous training, change communication, and feedback mechanisms that support interprofessional coordination and patient safety.