Strategies for improving clinical documentation in cancer care and implications for reproductive health: A scoping review Free

Background: High quality clinical documentation is central to ensuring optimal patient care, reducing medical errors, and empowering informed medical decision-making. Women of childbearing potential (WoCBP) diagnosed with cancer often do not have their reproductive health adequately discussed or documented. Documenting the reproductive health risks of cancer care is vital, since a patient's quality of life, treatment pathways, future fertility, as well as sexual and menstrual health can be significantly impacted when clinicians neglect this dimension of patient care. Strategies are needed to ensure the existing gap in the documentation process is narrowed. To identify the best possible range of strategies to address this problem, we conducted a scoping review with the aim of identifying studies evaluating the effectiveness of interventions designed to improve clinical documentation in oncology settings.

Methods: A systematic search was conducted on EMBASE, CINAHL, and PubMed for studies reporting on interventions to improve clinical documentation across the cancer care continuum. A team of 3 reviewers screened studies and extracted data. Full texts published between 2015—May 2025 were included if they reported on the effectiveness of an intervention to improve the quality and/or consistency of clinical documentation in cancer care. This scoping review was conducted in accordance with PRIMSA-ScR and JBI methodology guidelines.

Results: This scoping review identified 63 studies using a range of methodologies that investigate the effectiveness of interventions to improve documentation quality practices in cancer care. These interventions targeted clinicians, patients, systems, or a combination thereof. Several intervention sub-categories emerged. 1) Technology/electronic medical record (EMR) tools including structured templates/checklists, best practice advisories (BPAs), EMR standardisation, apps, and AI tools. 2) Clinician-targeted interventions including education, training, feedback reports, reminders, and behavioural incentives emerged as a sub-category implemented to boost documentation. 3) Patient-targeted interventions including care-navigators and patient resources were often engaged to empower and inform patients to discuss concerns with their providers. 4) Other system, workflow, and institutional changes were common throughout multiple studies; these interventions streamlined processes to make documentation less burdensome and engaged leadership to highlight documentation importance.

The majority of reviewed papers implemented bundled interventions from multiple sub-categories as part of a larger initiative. The most frequently targeted documentation domain was end-of-life care planning. Other documentation domains targeted included symptom burden and management, chemotherapy administration, cancer staging, and treatment toxicity. 7 papers reported on interventions aimed at improving the documentation of reproductive health in cancer care. Of these, all focused on fertility concerns, without addressing other important aspects of reproductive health such as contraception, sexual, or menstrual health. Key enablers for intervention success included use of evidence-based quality-improvement (QI) methods, interdisciplinary approaches, institutional support and leadership, and ease of integration into existing workflows. Key barriers included limitations on clinician time and priorities, EMR alert fatigue, and lack of clinician knowledge/training.

Conclusion: Limited evidence-based strategies exist specific to reproductive health documentation improvement. This highlights a critical practice and service gap. Overall, several promising approaches to improving clinician documentation behaviours have been implemented in oncology settings. These findings provide an evidence base and roadmap for developing and adapting intervention strategies to improve reproductive health documentation. For optimal chances of success, local and cultural systems and environments should be considered when developing or adapting intervention strategies.