Determinant Analysis of Electronic Medical Record Completeness Based on Physician Workload: A Systematic Literature Review

Aditya Ihza Dwi Pangestu; Muzakar Isa; Noor Alis Setiyadi

Aditya Ihza Dwi Pangestu Master's Program in Hospital Administration, Faculty of Medicine, Universitas Muhammadiyah Surakarta, Indonesia
Muzakar Isa Master's Program in Hospital Administration, Faculty of Medicine, Universitas Muhammadiyah Surakarta, Indonesia
Noor Alis Setiyadi Master's Program in Hospital Administration, Faculty of Medicine, Universitas Muhammadiyah Surakarta, Indonesia

Keywords: Clinical Workload, Documentation Completeness, Electronic Health Record, Physician, Literature Review

Abstract

Electronic Health Records (EHR) are crucial tools in the transformation of clinical governance and hospital information management. Despite offering numerous benefits, EHR implementation often conflicts with physicians’ heavy clinical workload, which risks reducing the level of documentation compliance and completeness. This incomplete medical data not only threatens patient safety but also hinders the insurance claims process and harms institutional operations. This study aims to systematically identify and analyze the factors determining EHR documentation completeness based on physician workload in inpatient facilities. The method used is a Systematic Literature Review (SLR) following the PRISMA 2020 framework. A comprehensive literature search was conducted using the Google Scholar database, focusing on publications from 2021 to 2026. From the initial identification to the final screening stage, 18 empirical study articles that met all inclusion criteria were extracted and analyzed thematically. The results of the literature review indicate that high operational burdens affect EHR completeness through two main determinant dimensions. First, the heavy workload during service hours triggers documentation delays, forcing physicians to perform additional administrative work outside of official duty hours (pajama time), resulting in reduced data accuracy. Second, the cognitive burden stemming from non-ergonomic EHR system interface designs leads to digital interaction fatigue (click fatigue) among medical personnel. In conclusion, excessive clinical and administrative workloads have been shown to significantly reduce the compliance rate for complete EHR documentation. Consequently, hospital management is advised to redesign system interfaces to better align with clinical workflows and provide support such as documentation assistants to optimize medical record quality without compromising physician well-being.

References

Adrian, H., Purnami, C. T., & Suryoputro, A. (2023). Analisis Dokumentasi Rekam Medis Elektronik di Fasilitas Pelayanan Kesehatan : Literature Review. Media Publikasi Promosi Kesehatan Indonesia (MPPKI), 6(11), 2086–2095. https://doi.org/10.56338/mppki.v6i11.4307

Ahmed, A., Chandra, S., Herasevich, V., Gajic, O., & Pickering, B. W. (2011). The Effect of Two Different Electronic Health Record User Interfaces on Intensive Care Provider Task Load, Errors of Cognition, and Performance. Critical Care Medicine, 39(7), 1626–1634. https://doi.org/10.1097/CCM.0b013e31821858a0

Almacen, A. M. B., & Cabaluna, A. Y. (2021). Electronic Document Management System (EDMS) implementation: Implications for the future of digital transformation in Philippine healthcare. Journal of Computer Science and Technology Studies, 3(2), 82-90. https://doi.org/10.32996/jcsts.2021.3.2.8

Alnami, R. E., & Almones, S. A. (2026). Impact Of Health Insurance Processes On Delayed Patient Referrals And Potential Implications For Physiological Regulatory Stability. The Review of Diabetic Studies, 26-35. https://doi.org/10.70082/h48q8819

Alobayli, F., O’Connor, S., Holloway, A., & Cresswell, K. (2023). Electronic Health Record Stress and Burnout Among Clinicians in Hospital Settings: A Systematic Review. Digital Health, 9. https://doi.org/10.1177/20552076231220241

Amelia, M., Purwadhi, & Santoso, B. (2025). Penerapan Rekam Medis Elektronik (RME) Mendukung Kinerja Dokter dan Petugas Rumah Sakit Gigi dan Mulut Maranatha Bandung. Journal of Scientech Research and Development, 6(2), 939–958. https://doi.org/10.56670/jsrd.v6i2.665

Asgari, E., Kaur, J., Nuredini, G., Balloch, J., Taylor, A. M., Sebire, N., Robinson, R., Peters, C., Sridharan, S., & Pimenta, D. (2024). Impact of Electronic Health Record Use on Cognitive Load and Burnout among Clinicians: Narrative Review. JMIR: Medical Informatics, 12, e55499. https://doi.org/10.2196/55499

Budd, J. (2023). Burnout Related to Electronic Health Record Use in Primary Care. Journal of Primary Care & Community Health, 14. https://doi.org/10.1177/21501319231166921

Burhan, L., & Nadjib, M. (2023). Hubungan Persepsi Pengguna terhadap Keberhasilan Implementasi Rekam Medis Elektronik: Tinjauan Literatur. Jurnal Kesehatan Tambusai, 4(2), 1532–1545. https://doi.org/10.31004/jkt.v4i2.15536

Chatta, H. P., Thrigulla, S. R., Mane, S., & Prasad, G. P. (2024). Development of Medical Record Science in India and Transition from Paper-based Record to Electronic Medical Records: A Historical Account Focusing on the Ayush Sector. Journal of Indian Medical Heritage, 3(1), 15-26.

Garg, V., & Mishra, G. (2026). Smart Financial Surveillance: Blockchain and Explainable AI for Fraud Detection in Smart Healthcare Organizations. Blockchain Solutions for Securing Internet of Things Networks, 225-266. https://doi.org/10.1002/9781394417131.ch9

Holmgren, A. J., Thombley, R., Sinsky, C. A., & Adler-Milstein, J. (2023). Changes in Physician Electronic Health Record Use With the Expansion of Telemedicine. Jama: Internal Medicine, 183(12), 1357. https://doi.org/10.1001/jamainternmed.2023.5738

Krisdarmanto, R. A., Sumijatun, S., & Ismaya, S. B. (2025). Pengaruh Beban Kerja, Komitmen, dan Kepuasan Kerja terhadap Kinerja Dokter Spesialis dalam Pengisian Rekam Medis Elektronik di Ruang Rawat Inap Rumah Sakit Bhayangkara TK III Hoegeng Imam Santoso Banjarmasin. Jurnal Teknologi Informasi, 11(2), 210–230. https://doi.org/10.52643/jti.v11i2.6723

Kruse, C. S., Mileski, M., Dray, G., Johnson, Z., Shaw, C., & Shirodkar, H. (2022). Physician Burnout and the Electronic Health Record Leading Up to and During the First Year of COVID-19: Systematic Review. Journal of Medical Internet Research, 24(3), e36200. https://doi.org/10.2196/36200

Lee, C., Britto, S., & Diwan, K. (2024). Evaluating the Impact of Artificial Intelligence (AI) on Clinical Documentation Efficiency and Accuracy Across Clinical Settings: A Scoping Review. Cureus, 16(11). https://doi.org/10.7759/cureus.73994

Levy, D. R., Withall, J. B., Mishuris, R. G., Tiase, V., Diamond, C., Douthit, B., Grabowska, M., Lee, R. Y., Moy, A. J., Sengstack, P., Adler-Milstein, J., Detmer, D. E., Johnson, K. B., Cimino, J. J., Corley, S., Murphy, J., Rosenbloom, S. T., Cato, K., & Rossetti, S. C. (2024). Defining Documentation Burden (DocBurden) and Excessive DocBurden for All Health Professionals: A Scoping Review. Applied Clinical Informatics, 15(05), 898–913. https://doi.org/10.1055/a-2385-1654

Lou, S. S., Lew, D., Harford, D. R., Lu, C., Evanoff, B. A., Duncan, J. G., & Kannampallil, T. (2022). Temporal Associations Between EHR-Derived Workload, Burnout, and Errors: a Prospective Cohort Study. Journal of General Internal Medicine, 37(9), 2165–2172. https://doi.org/10.1007/s11606-022-07620-3

Mattingly, T. J., & O'neal, M. A. D. E. L. I. N. E. (2026). Medicaid Work Requirements: Engaging Clinics And Pharmacies To Prevent Disenrollment. The Milbank Quarterly, 104(1), 48-57. https://doi.org/10.1111/1468-0009.70065

Moy, A. J., Schwartz, J. M., Chen, R., Sadri, S., Lucas, E., Cato, K. D., & Rossetti, S. C. (2021). Measurement of Clinical Documentation Burden among Physicians and Nurses Using Electronic Health Records: A Scoping Review. Journal of the American Medical Informatics Association, 28(5), 998–1008. https://doi.org/10.1093/jamia/ocaa325

Munazhifah, M., Yulia, N., Dewi, D. R., & Fannya, P. (2023). Identifikasi Kelengkapan Pengisian Rekam Medis Elektronik Pasien Rawat Inap di RSKD Duren Sawit Jakarta Tahun 2022. Sehat Rakyat: Jurnal Kesehatan Masyarakat, 2(1), 68–75. https://doi.org/10.54259/sehatrakyat.v2i1.1467

Murad, M. H., Vaa Stelling, B. E., West, C. P., Hasan, B., Simha, S., Saadi, S., Firwana, M., Viola, K. E., Prokop, L. J., Nayfeh, T., & Wang, Z. (2024). Measuring Documentation Burden in Healthcare. Journal of General Internal Medicine, 39(14), 2837–2848. https://doi.org/10.1007/s11606-024-08956-8

Nurhayati, N., Suryadi, A., Pasa, I. Y., & Purwanto, M. A. (2025). Studi Literatur: Kontribusi Rekam Medis Elektronik dan Clinical Decision Support System dalam Mendukung Pengambilan Keputusan Klinis. Prosiding Seminar Informasi Kesehatan Nasional, 280–293. https://doi.org/10.47701/4w91rx73

Olakotan, O., Samuriwo, R., Ismaila, H., & Atiku, S. (2025). Usability challenges in electronic health records: impact on documentation burden and clinical workflow: a scoping review. Journal of Evaluation in Clinical Practice, 31(4), e70189. https://doi.org/10.1111/jep.70189

Overhage, J. M., & McCallie, D. (2020). Physician Time Spent Using the Electronic Health Record during Outpatient Encounters. Annals of Internal Medicine, 172(3), 169–174. https://doi.org/10.7326/M18-3684

Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., … Moher, D. (2021). The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews. British Medical Journal, n71. https://doi.org/10.1136/bmj.n71

Patel, S., Gayakvad, B., Solanki, R., Patel, R., & Khunt, D. (2023). Towards the digitization of healthcare record management. Human‐Machine Interface: Making Healthcare Digital, 411-447. https://doi.org/10.1002/9781394200344.ch16

Rotenstein, L. S., Holmgren, A. J., Healey, M. J., Horn, D. M., Ting, D. Y., Lipsitz, S., Salmasian, H., Gitomer, R., & Bates, D. W. (2022). Association Between Electronic Health Record Time and Quality of Care Metrics in Primary Care. Jama: Network Open, 5(10), e2237086. https://doi.org/10.1001/jamanetworkopen.2022.37086

Sarifa, S., Putu G, A., & Yulius, D. (2026). Analisis Pengaruh Pengetahuan, Kedisiplinan dan Beban Kerja Dokter dalam Kelengkapan Pengisian Rekam Medis (Elektronik) Pasien Rawat Inap untuk Peningkatan Klaim Asuransi di RS Islam Al-Muchtar Karawang (Jawa Barat). Jurnal Manajemen Dan Administrasi Rumah Sakit Indonesia (MARSI), 10(1), 361–373. https://doi.org/10.52643/marsi.v10i1.8020

Selvakumar, P., Parthiban, R., Manjunath, T. C., Saradha, S., Ali, S. M., & Naresh, K. K. (2026). Generative AI Applications in Nursing Practice and Clinical Decision-Making. In Breakthroughs in Smart Nursing With Generative AI (pp. 21-48). IGI Global Scientific Publishing. https://doi.org/10.4018/979-8-3373-8247-0.ch002

Singh, A., & Jindal, O. (2026). Enhancing hospitalized patients medication safety by focusing on electronic medical record system: a quality function deployment application. International Journal of Pharmaceutical and Healthcare Marketing, 1-25. https://doi.org/10.1108/IJPHM-07-2025-0147

Sun, X., Liu, X., Chang, X., Hu, N., Qi, X., & Li, X. (2026). Technophobia and Its Associated Factors Among Registered Nurses in China: A Cross‐Sectional Multicenter Study. Journal of Nursing Management, 2026, 9935996. https://doi.org/10.1155/jonm/9935996

van Limpt, G. J., Molenaar, M. A., Jamaludin, F. S., van Oostveen, C. J., Paulus, F., Schultz, M. J., ... & Buiteman‐Kruizinga, L. A. (2026). Methods and Instruments to Measure ICU Healthcare Professionals' Workload Related to Medical Technology—Protocol for a Scoping Review. Nursing in Critical Care, 31(2), e70373. https://doi.org/10.1111/nicc.70373

Wu, Y., Wu, M., Wang, C., Lin, J., Liu, J., & Liu, S. (2024). Evaluating the prevalence of burnout among health care professionals related to electronic health record use: systematic review and meta-analysis. JMIR Medical Informatics, 12, e54811.

Wulansari, W. T., Sundari, S., Prasetyo, A., Hutapea, Y., HT, A., & Tarmizi, A. (2026). The strategic role of information systems in enhancing error reduction and user satisfaction: A mediation approach. Quality Management Journal, 1-34. https://doi.org/10.1080/10686967.2025.2611728

Xu, Y., Tong, Y., Liao, S. S., & Zhou, G. (2026). When knowledge professionals meet technology: physicians’ use of electronic medical record systems and impact on job performance. Internet Research, 1-24. https://doi.org/10.1108/INTR-01-2025-0149