Emojis are widely used in everyday digital communication, and a new research letter in JAMA Network Open suggests they are also starting to appear in clinical documentation. Researchers at Michigan Medicine reviewed more than 218 million electronic health record notes written between January 2020 and September 2025 to examine how often emojis were used, where they appeared, and what they may signal about clinician-patient communication.
Emoji use was uncommon overall. The team identified 372 different emojis across 4,162 notes, but usage increased over time. From 2020 through 2024, emojis appeared in about 1.4 notes per 100,000 notes. By the third quarter of 2025, that rate rose to 10.7 notes per 100,000.
When emojis did appear, they were often used more than once in a note. About 24% of emoji-containing notes included multiple emojis, and the median number of emojis in these notes was four. One note contained as many as 32 emojis.
Most emojis were found in patient-facing communication rather than traditional clinical documentation. The most common note types were portal messages sent to patients (36%) and telephone encounters (29%). Emojis also appeared in encounter summaries (15%), progress notes (14%), and patient instructions (6%). Notably, the researchers reported that patients could not enter emojis through the Epic portal used at this institution, and no emojis were found in more than 34 million patient-written portal messages.
The most frequently used emojis included a smiling face, telephone receiver, calendar, "no" symbol, and an eye. This pattern suggests emojis were used both for emotional tone and as quick visual cues for communication or scheduling. Overall, most emojis belonged to the "smileys and emotion" category (59%), followed by "objects" (21%) and "people and body" (18%).
To better understand the context, the researchers manually reviewed 200 emoji-containing notes from 2024 and 2025. In most cases, emojis were added by clinicians or staff rather than patients (89%). About two-thirds of notes (64%) were directed to patients or family members. Emojis were most often used on their own (57%) or added to written text for emphasis or tone (42%), and rarely used as a substitute for words (1%).
The researchers note that emojis may serve a psychological role in communication by signaling warmth, reassurance, or approachability, which can matter in patient-facing messaging. However, they also highlight potential risks: emojis can be interpreted differently depending on the patient's age, cultural background, and familiarity with digital communication.
While the study does not assess patient outcomes or whether emojis improved understanding, it suggests emoji use may be increasing as patient messaging becomes a larger part of clinical work. The researchers recommend that health systems consider whether guidance is needed to support clear, consistent communication in the electronic health record.
The authors declared having no competing interests.
Source: JAMA Network Open