Abstract
Background Documentation burden, defined as the need to complete unnecessary documentation elements
in the electronic health record (EHR), is significant for nurses and contributes to
decreased time with patients as well as burnout. Burden increases when new documentation
elements are added, but unnecessary elements are not systematically identified and
removed.
Objectives Reducing the burden of nursing documentation during the inpatient admission process
was a key objective for a group of nurse experts who collaboratively identified essential
clinical data elements to be documented by nurses in the EHR.
Methods Twelve health care organizations used a data-driven process to evaluate inpatient
admission assessment data elements to identify which elements were consistently deemed
essential to patient care. Processes used for the twelve organizations to reach consensus
included identifying: (1) data elements that were truly essential, (2) which data
elements were explicitly required during the admission process, and (3) data elements
that must be documented by a registered nurse (RN).
Result The result was an Admission Patient History Essential Clinical Dataset (APH ECD)
that reduced the amount of admission documentation content by an average of 48.5%.
Early adopters experienced an average reduction of more than two minutes per admission
history documentation session and an average reduction in clicks of more than 30%.
Conclusion The creation of the essential clinical dataset is an example of combining evidence
from nursing practice within the EHR with a set of predefined guiding principles to
decrease documentation burden for nurses. Establishing essential documentation components
for the adult admission history and intake process ensures the efficient use of bedside
nurses' time by collecting the right (necessary) information collected by the right
person at the right time during the patient's hospital stay. Determining essential
elements also provides a framework for mapping components to national standards to
facilitate shareable and comparable nursing data.
Keywords
electronic health records - documentation burden - admission history - registered
nurse - health information technology - inpatient admission - clinical care - clinical
informatics - documentation elements
