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Appl Clin Inform 2025; 16(03): 628-639
DOI: 10.1055/a-2561-3960
Review Article

Relationship between Additional Required Nursing Documentation and Patient Outcomes: A Scoping Review

Rachel Y. Lee    *
1   Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, United States
,
Jennifer Thate   *
1   Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, United States
2   Siena College, Loudonville, New York, United States
,
Jennifer Withall
1   Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, United States
,
Po-Yin Yen
3   Institute for Informatics, Data Science & Biostatistics, Washington University School of Medicine, St. Louis, Missouri, United States
,
Kenrick Cato
4   University of Pennsylvania, Philadelphia, Pennsylvania, United States
5   Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
,
Sarah C. Rossetti
1   Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, United States
6   Columbia University Irving Medical Center, School of Nursing, New York, New York, United States
› Author Affiliations
Funding National Institute of Nursing Research (NINR grant no.: 1R01NR016941), COmmunicating Narrative Concerns Entered by RNs (CONCERN): Clinical Decision Support Communication for Risky Patient States); American Nurses Foundation Reimagining Nursing Initiative; Essential Nurse Documentation: Studying EHR Burden during COVID-19 (ENDBurden) Agency for Healthcare Research and Quality (AHRQ; grant no.: AHRQ R01HS0284).
› Further Information
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Abstract

Background

Although many aspects of nursing documentation are considered an essential part of clinical communication and care coordination, other types of nursing documentation have been implemented to meet compliance and secondary uses. Adding required documentation without carefully assessing its association with patient outcomes adds excessive documentation burden on nurses. There is a gap in the evidence of the association between additional required nursing documentation and improvements in patient outcomes.

Objectives

This study aimed to synthesize and describe the state of the evidence on the relationship between adding required electronic nursing documentation and improved patient outcomes in inpatient hospital settings.

Methods

Databases were searched using relevant terms for original studies examining the effects of additional required nursing documentation. Two authors screened titles, abstracts, and full texts for eligibility criteria. PubMed, CINAHL (EBSCO), Web of Science, and Embase were searched for data from January 2011 to May 2023.

Results

A total of 47 studies were included. Of the studies reviewed, 57.4% (n = 27) focused only on process measures, primarily measuring documentation compliance, and 42.6% (n = 20) studies included patient outcome measures such as infection rates, length of stay, and falls. Of these studies 45% (n = 9) reported statistically significant relationship between required nursing documentation and improved patient outcomes. Overall quality of evidence was generally low, with 72% (n = 34) being quality improvement studies and only one study being a randomized controlled trial.

Conclusion

The findings of this scoping review suggest an assumed, yet unverified, connection between added required nursing documentation and improved patient outcomes that is not substantiated by high-quality empirical evidence. The paucity of studies with significant findings—and the methodological weaknesses of those that report them—suggest the need for critical examination of documentation practices that are truly beneficial to patient outcomes versus those documentation practices that are excessively burdensome.

Keywords

nursing documentation - documentation burden - nursing informatics - inpatient care - electronic health records

Protection of Human and Animal Subjects

No human subjects were involved in this study.


Authors' Contributions

Conceptualization: R.L., J.T., and S.C.; Data curation, formal analysis, methodology: R.L. and J.T.; Writing—original draft: R.L. and J.T.; Writing—review and editing: R.L., J.T., J.W., P.Y., K.C., and S.C.


* Denotes co-primary author.


Supplementary Material



Publication History

Received: 27 August 2024

Accepted: 18 March 2025

Accepted Manuscript online:
19 March 2025

Article published online:
09 July 2025

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