Implementing Best Practices to Redesign Workflow and Optimize Nursing Documentation in the Electronic Health Record.

Area of Science:

• Health Informatics
• Clinical Workflow Optimization
• Quality Improvement in Healthcare

Background:

• Electronic health records (EHR) present significant documentation burdens.
• EHR usability and functionality are often fragmented, hindering clinical information synthesis.
• Limited best practices exist for aligning EHR documentation with clinical workflows.

Purpose of the Study:

• To improve EHR performance by redesigning patient assessment templates.
• To reduce redundant tasks and non-value-added activities within EHR documentation.
• To implement best practices for streamlining EHR data entry and clinical workflow.

Main Methods:

• A pre-/post-design quality improvement approach was used.
• Usability modifications targeted efficiency, redundancy reduction, and workflow navigation.
• Documentation steps and time were analyzed using timestamp data and video motion-time recording (Keystrok Level Model).

Main Results:

• An 18.5% decrease in overall EHR time was observed.
• Total time in flowsheets decreased by 7–12%.
• Reassessment documentation time decreased by 1.5–6.5 minutes per patient, with an 88–97% reduction in steps.

Conclusions:

• Workflow redesign improved EHR usability and functionality, decreasing documentation time and click burden.
• Significant time savings per shift can be reallocated to patient care.
• Revised documentation practices reduce staff workload, enhance quality, and improve satisfaction.