Interdisciplinary Optimization of Admission Documentation: Reducing the Bloat.

Area of Science:

• Health Informatics
• Clinical Documentation Improvement
• Nursing Workflow Optimization

Background:

• Electronic health records (EHRs) aim to improve data quality but can increase nursing workload.
• Admission forms often contain duplicative or unnecessary fields, leading to inefficiencies.
• Optimizing EHR forms is crucial for balancing data quality with clinical efficiency.

Purpose of the Study:

• To evaluate the impact of removing duplicative/unnecessary fields and reordering sections on the Adult Admission History Form.
• To enhance meaningful patient documentation and reduce the perceived burden on nurses.
• To improve the usability and efficiency of the EHR admission process.

Main Methods:

• An interdisciplinary team of ~60 clinicians reviewed and revised the Adult Admission History Form.
• 251 fields were evaluated, with the form reduced to 124 fields, decreasing unfielded data by 31%.
• Quantitative analysis of completion time and free text usage, alongside pre/post-intervention nurse surveys.

Main Results:

• The number of fields was reduced from 251 to 124, decreasing unfielded data by 31%.
• Average form completion time decreased by 2.88 minutes.
• Nurse satisfaction significantly improved regarding usability, usefulness, flow, length, and time to complete, with a 36.71% reduction in free text advance directive use.

Conclusions:

• Optimizing the Adult Admission History Form through interdisciplinary collaboration is effective.
• Streamlined documentation increases data quality while reducing clinical workload.
• This process enhances the efficiency and user experience of electronic health records.