Nursing Praxis for Reducing Documentation Burden Within Nursing Admission Assessments

Area of Science:

• Nursing Informatics
• Quality Improvement Science
• Healthcare Administration

Background:

• Nursing documentation is critical but time-consuming.
• Electronic health records (EHRs) present challenges in efficiency.
• Optimizing the nursing admission encounter is essential for patient care.

Purpose of the Study:

• To revise nursing admission documentation content for efficiency.
• To reduce time and clicks in electronic charting.
• To quantify time returned to patient care and associated costs.

Main Methods:

• Scholarly assessment of current nursing admission information.
• Content revision based on regulatory needs, nurse-sensitive data, and essentiality.
• Implementation across three pilot medical-surgical units.
• Leveraging nurse executive competencies and the nursing process.

Main Results:

• Reduced nursing documentation burden by 29% in clicks.
• Decreased time to document an admission encounter by 34%.
• Projected return of 1016 hours per year to patient care activities across pilot units.

Conclusions:

• Nursing documentation praxis significantly improves efficiency.
• Streamlined documentation enhances focus on nurse-patient interactions.
• Quantified cost-saving potential and time recovery for patient care.