Examining Clinical Documentation as a Key Component of Health Information Technology: A Qualitative Case Series

Context: Previous researchers have identified that athletic trainers (ATs) desire more guidance regarding documentation during professional education and on-the-job training. Objective: Examine the professional socialization of ATs' documentation practices from multiple perspectives. Design: Qualitative case series. Setting: Zoom audio interviews. Patients or Other Participants: Using purposeful and snowball sampling, we recruited participant triads including (1) a newly credentialed AT (certified ≤1 year), (2) their current supervisor, and (3) an educator from their professional program. Four triads, mostly from the college/university setting, participated in the study (9 women, 3 men, age = 35.08 ± 9.24 years), averaging 11.66 ± 9.44 years as an AT (educators = 17.05 ± 2.50, supervisors = 13.75 ± 8.06, ATs = 1.00 ± 0.00). Data Collection and Analysis: We developed and validated 3 semistructured interview guides, then piloted them with 3 individuals. Three researchers inductively analyzed interviews using the consensual qualitative research approach through 4 rounds of coding and consensus meetings. We analyzed data collectively, followed by within- and between-cases analyses of each triad's data and confirmed saturation. Trustworthiness was obtained via multiple-analyst and source triangulation. Results: Analysis revealed 4 domains representative of all cases, including (1) electronic medical records (EMRs), (2) lack of point-of-care documentation, (3) differences and accountability, and (4) learning. Although EMRs are central to completing high-quality documentation, ATs face challenges integrating EMRs into professional education. We found that point-of-care documentation is not a strongly implemented behavior, contributing to inefficient documentation practices. It is common for ATs to use different approaches to documentation, but employer accountability improves consistency within workplaces and learning environments. Lastly, we found that learning over time through classroom and clinical experience facilitates the transferability of quality on-the-job documentation. Conclusions: Supervisors should establish workplace guidelines and onboarding to support new ATs' documentation practices. Educators can facilitate high-quality documentation by teaching effective documentation strategies, engaging students in EMR use, and consistently engaging students in clinical documentation during clinical education experiences.