Analysis of 218.1 million notes from 1.6 million patients' electronic health records revealed growing use of emojis.
The results, published in JAMA Network Open , found 372 emojis within 4,162 notes between 2020 and 2025.
The incidence of emojis was higher than that found in prior studies of clinical texting systems .
"In this exploratory study we set out to determine if emojis, which are often associated with text messaging and social media, have made their way into medical records. Surprisingly, we uncovered hundreds of distinct emojis being used," said David A. Hanauer M.D., M.S., lead author and Clinical Professor of Pediatrics and Learning Health Sciences at the University of Michigan Medical School.
"These were scattered throughout clinical notes but were mostly found in brief messages sent to patients via the portal. While emoji use in medical records is still rare, their use seems to be on the rise, raising important questions about age-related differences in use and interpretation, as well as best practices for digital clinician–patient communication."
The most common kind of emojis used were smileys/emoticons (58.5%), followed by objects (21.2%) and people and body (17.6%).
The most used emoji was the smiling face with smiling eyes (1,772 instances), followed by the telephone receiver (544) and the calendar (429). The hospital building emoji ranked 30th with just 30 instances.
The majority of the notes containing emojis were sent from a clinical team to a patient or family. (As the University of Michigan patient portal does not allow patients to add their own emojis to messages, most of the patient-originating emojis were copied into notes from emails or text messages.)
Only 1% of emojis were used to replace a word — e.g. using the pill emoji in lieu of the word medicine. The majority were used for emphasis or for their own sake.
Still, researchers believe the use of emojis in electronic health records creates the potential for miscommunication, especially among older patients. Records for patients aged 70-79 years old had the second-most emojis, after 10–19-year-olds.
"Given the small but growing presence of emojis in clinical documentation, we recommend that healthcare institutions proactively develop guidelines for their use to maintain clarity and professionalism in clinical communications," Hanauer said.
"One of the first steps to understanding the impact of emojis is simply being able to measure their use, which is still a challenging task. Future work should investigate how emojis might affect patient understanding, trust and outcomes — and explore whether these playful digital symbols offer new opportunities or pose unintended challenges in electronic health record communication."
