Defining an Essential Clinical Dataset for Admission Patient History to Reduce Nursing Documentation Burden

Area of Science:

• Nursing Informatics
• Health Information Management
• Clinical Documentation

Background:

• Nursing documentation burden in EHRs significantly impacts patient care time and contributes to nurse burnout.
• Unnecessary documentation elements accumulate in EHRs without systematic removal processes.

Purpose of the Study:

• To reduce nursing documentation burden during inpatient admissions.
• To collaboratively identify essential clinical data elements for nursing documentation in EHRs.

Main Methods:

• Twelve healthcare organizations employed a data-driven consensus process to evaluate admission assessment data elements.
• Identified essential, required, and RN-documented data elements for patient care.

Main Results:

• Developed the Admission Patient History Essential Clinical Dataset (APH ECD).
• Reduced admission documentation content by an average of 48.5%.
• Achieved average time savings of over two minutes and a 30% reduction in clicks per documentation session.

Conclusions:

• The APH ECD decreases documentation burden by focusing on essential information collected by nurses.
• Ensures efficient use of nursing time by collecting necessary data at the right time.
• Provides a framework for standardizing nursing data for improved interoperability.