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Area of Science:

  • Health Informatics
  • Nursing Informatics
  • Clinical Documentation

Background:

  • Documentation burden is a pervasive issue in healthcare.
  • Electronic Health Records (EHRs) are critical but contribute to this burden.
  • Understanding documentation burden is key to improving healthcare efficiency.

Purpose of the Study:

  • To quantify the manual documentation burden on nurses within EHR flowsheets.
  • To assess the contribution of automated device data to total flowsheet entries.
  • To identify potential strategies for reducing documentation workload.

Main Methods:

  • Quantified manual data entries in EHR flowsheets over a 12-hour shift.
  • Analyzed data from Intensive Care Unit (ICU) and acute care settings.
  • Calculated the proportion of automated device data entries.

Main Results:

  • Mean manual flowsheet entries: 633-689/shift (ICU), 631-875/shift (acute care).
  • Automated device data comprised only 5-20% of total entries.
  • Nurses documented one data point every 0.82-1.14 minutes.

Conclusions:

  • Manual documentation in EHR flowsheets represents a substantial time commitment for nurses.
  • Current automation levels are insufficient to significantly alleviate this burden.
  • Enhanced automation and novel input methods (e.g., voice recognition) could improve efficiency and data richness.