Emojis and emoticons — small digital symbols used to express emotions, ideas, and concepts — have become a ubiquitous feature of informal digital communication. But how often do these symbols actually appear within formal clinical documentation? A new cross-sectional study published in JAMA Network Open investigated the frequency, context, and characteristics of emoji use in electronic health record (EHR) notes at a large academic medical centre, revealing that while emojis remain rare in clinical documentation overall, they are present across a surprisingly wide range of note types and express a breadth of communicative functions.
Drawing on a dataset of 218.1 million clinical notes from 1.6 million patients created between January 1, 2020, and September 30, 2025, at Michigan Medicine, researchers systematically identified all emoji occurrences across more than five years of documentation. Among these, 4162 notes contained at least one emoji, and the team identified 372 distinct emojis used in clinical text — far more than previously reported in clinician-to-clinician texting studies that found only about 42 unique emojis. Approximately 24.3% of emoji-containing notes included more than one emoji, with a maximum of 32 emojis in a single note and a median of four per note.
CLINICAL SUMMARY
What was examined
The frequency, distribution, and characteristics of emoji use in over 218 million electronic health record clinical notes were analysed from a large academic medical centre between 2020 and 2025.
Key findings
- Only 4162 notes contained one or more emojis, with 372 distinct emojis identified; emoji use increased somewhat by late 2025 but remained rare overall.
- Emoji use was predominantly clinician-introduced and often appeared in patient-facing notes; most were uniquely added and conveyed emotion or feeling.
Clinical implications
- Even rare emoji use can have implications for clinician–patient communication and documentation clarity, especially if interpretations vary across age groups and contexts.
- Health care organisations may consider tracking and developing guidance on emoji inclusion in clinical text to support clear and professional documentation.
Rates of emoji use in clinical notes remained very low overall. From 2020 through 2024, there were about 1.4 notes with emojis per 100 000 notes, but this increased to 10.7 per 100 000 notes by the third quarter of 2025, suggesting either a soft upward trend or episodic bursts of usage.
The researchers also analysed 200 randomly selected emoji-containing notes from 2024 and 2025 to characterise how emojis were being used across several dimensions. They found that 89.0% of emojis were introduced by members of the clinical team, while 10.5% came from patients or their families. In terms of intended audience, 64.0% of emojis appeared to be directed at patients or family members, and 35.0% were aimed at clinical colleagues, with high agreement between independent raters.
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Regarding how emojis were incorporated into clinical text, 58.5% were uniquely added rather than pulled from reusable templates, while 41.0% came from templated note segments. Emojis also served different communicative roles: 59.5% conveyed emotion or feeling, compared with 40.5% that appeared to be informational or symbolic rather than emotional, and most appeared as stand-alone elements, rather than replacing specific clinical language.
The study also examined portal messages sent to patients that contained emojis, revealing an unexpected distribution by age group. While emoji use was lowest in some adult decades, such as ages 30–39 (2.5 notes with emojis per 100 000 portal messages), higher rates appeared both in younger patients aged 10–19 (3.8 per 100 000) and older adults aged 70–79 (3.3 per 100 000).
In their discussion, the authors emphasise that although emoji inclusion in clinical documentation was infrequent, the breadth of different emojis used and their presence in both provider- and patient-facing contexts raise interesting questions about communication norms in digital health records. Emojis’ varied interpretations — especially across different age groups — underscore potential risks of misinterpretation, particularly in patient communications, even if their use remains uncommon.
The authors suggest that health systems might consider monitoring emoji use and developing documentation guidelines to clarify appropriate contexts and reduce ambiguity. They also note limitations of their study, including its single-centre design, inability to directly link emoji use with clinical outcomes, and lack of data on how clinicians or patients interpret emojis. Future research could explore how emoji use affects communication effectiveness and understanding within and beyond clinical teams.
Paper: Hanauer DA, et al. Emoji Use in the Electronic Health Record. JAMA Netw Open. 2026;9(1):e2553770. doi:10.1001/jamanetworkopen.2025.53770 Access online here.
