Effect of Implementing Admission History Optimization on Perceived Nurse Documentation Burden

Abstract

Electronic health records (EHR) and computer-based documentation is a powerful tool which has been adopted extensively in the last twenty years. The effect of EHR integration on staff has not been well studied, especially among nurses.

Purpose

The purpose is to investigate how optimization of nursing documentation effects the burden of documentation on nurses.

Methods

This project evaluated the admission history documentation at a community hospital that used essential data sets (EDS) to optimize the documentation process for nursing. To evaluate the documentation burden, the Burden of Documentation for Nurses and Midwives (BurDoNsaM) survey will be used before implementation and three months post-implementation.

Findings

There were few statistically significant differences felt by nursing staff after admission history optimization. Some responses were found to have slight positive differences indicating that the optimization did positively affect nurse documentation burden.

Originality

EDS are being used to restructure EHR documentation. This project evaluated whether the documentation had any significant change on nursing workflow as perceived by nurses. The findings of this project are crucial to understanding that relieving the nursing documentation burden is more complicated than simply reducing the amount of elements required.