How extra nursing notes point to deterioration.

Area of Science:

• Nursing Informatics
• Patient Safety
• Clinical Documentation

Background:

• Optional nursing documentation in electronic health records (EHRs) can reflect nurse concern.
• This documentation may serve as an early indicator of patient risk for adverse outcomes.

Purpose of the Study:

• To investigate the association between the extent of optional nursing documentation and patient outcomes.
• To determine if increased nursing notes predict critical events such as patient death or cardiac arrest.

Main Methods:

• Retrospective analysis of EHR data from a US healthcare setting.
• Statistical analysis to correlate the volume of optional nursing notes and vital sign entries with patient mortality and cardiac arrest events.

Main Results:

• A statistically significant association was found between higher volumes of optional nursing documentation (comments and vital signs) and increased rates of patient death.
• Similarly, increased optional documentation correlated significantly with a higher incidence of cardiac arrest.

Conclusions:

• Optional nursing documentation in EHRs can be a valuable marker for predicting patient deterioration.
• Nurses should recognize that increased documentation may indicate heightened patient risk, prompting timely clinical intervention.