Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 Feb 18;49(1):28.
doi: 10.1007/s10916-025-02157-4.

Artificial Intelligence (AI) - Powered Documentation Systems in Healthcare: A Systematic Review

Aisling Bracken  1 , Clodagh Reilly  2 , Aoife Feeley  3 , Eoin Sheehan  4 , Khalid Merghani  5 , Iain Feeley  5
Affiliations

Artificial Intelligence (AI) - Powered Documentation Systems in Healthcare: A Systematic Review

Aisling Bracken et al. J Med Syst. .

Abstract

Artificial Intelligence (AI) driven documentation systems are positioned to enhance documentation efficiency and reduce documentation burden in the healthcare setting. The administrative burden associated with clinical documentation has been identified as a major contributor to health care professional (HCP) burnout. The current systematic review aims to evaluate the efficiency, quality, and stakeholder opinion regarding the use of AI-driven documentation systems. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines a comprehensive search was conducted across PubMed, Embase and Cochrane library. Two independent reviewers applied inclusion and exclusion criteria to identify eligible studies. Details of AI technology, document type, document quality and stakeholder experience were extracted. The review included 11 studies. All included studies utilised Chat generated pretrained transformer (Chat GPT, Open AI, CA, USA) or an ambient AI technology. Both forms of AI demonstrated significant potential to improve documentation efficiency. Despite efficiency gains, the quality of AI-generated documentation varied across studies. The heterogeneity of methods utilised to assess document quality influenced interpretation of results. HCP opinion was generally positive, users highlighted ease of use and reduced task load as primary benefits. However, HCPs also expressed concerns about the reliability and validity of AI-generated documentation. Chat GPT and ambient AI show promise in enhancing the efficiency and quality of clinical documentation. While the efficiency benefits are clear, the challenges associated with accuracy and consistency need to be addressed. HCP experiences indicate a cautious optimism towards AI integration, however reliability will depend on continued refinement and validation of the technology.

Keywords: Ambient intelligence; Artificial Intelligence (AI); Chat GPT; Medical documentation.

PubMed Disclaimer

Conflict of interest statement

Declarations. Ethics Approval and Consent to Participate: Not applicable. Competing Interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
PRISMA Flowchart
See this image and copyright information in PMC

References

    1. Bongurala AR, Save D, Virmani A, Kashyap R. Transforming Health Care With Artificial Intelligence: Redefining Medical Documentation. Mayo Clinic Proceedings: Digital Health. 2024;2(3):342-7.
    1. Wu Y, Wu M, Wang C, Lin J, Liu J, Liu S. Evaluating the Prevalence of Burnout Among Health Care Professionals Related to Electronic Health Record Use: Systematic Review and Meta-Analysis. JMIR Medical Informatics. 2024;12:e54811. - PMC - PubMed
    1. Davenport T, Kalakota R. The potential for artificial intelligence in healthcare. Future Healthc J. 2019;6(2):94-8. - PMC - PubMed
    1. Boscardin CK, Gin B, Golde PB, Hauer KE. ChatGPT and Generative Artificial Intelligence for Medical Education: Potential Impact and Opportunity. Acad Med. 2024;99(1):22-7. - PubMed
    1. Aaron A. Tierney P, Gregg Gayre, MD, Brian Hoberman, MD, MBA, Britt Mattern, MBA, Manuel Ballesca, MD, Patricia Kipnis, PhD, Vincent Liu, MD, MS, and Kristine Lee, MD. Ambient Artificial Intelligence Scribes to Alleviate the Burden of Clinical Documentation. New England Journal of Medicine Catalyst. 2024;5 No. 3.

Publication types

LinkOut - more resources