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Preparing for the Future: Establishing a National Consensus on Nursing Crisis Documentation
Stephanie H Hoelscher1, Susan McBride, Serena Bumpus
1Author Affiliations: Texas Tech University Health Sciences Center, Lubbock (Dr Hoelscher); Texas Tech University Health Sciences Center School of Nursing, Lubbock (Dr McBride); and Ascension Health, Leander, TX (Dr Bumpus).
Computers, Informatics, Nursing : CIN
|February 3, 2023
Summary
Electronic health records cause clinician distress. A Texas study found gaps in crisis nursing documentation, informing strategies to improve usability and reduce burden.
Area of Science:
- Nursing Informatics
- Health Information Technology
- Healthcare Policy
Background:
- Electronic health records (EHRs) contribute to clinician dissatisfaction and burden globally.
- Poor EHR usability and excessive data collection negatively impact clinician performance and patient outcomes in the US.
- Nursing documentation requirements are a significant source of stress for healthcare professionals.
Purpose of the Study:
- To review a 2020 Texas pilot study on nursing documentation during crisis situations.
- To achieve consensus among nursing informatics experts regarding current documentation status and potential modifications.
- To identify strategies for alleviating documentation burden, particularly during crises.
Main Methods:
- Engagement of nursing informatics experts statewide.
- Utilization of subject matter expert focus groups.
- A high-level Delphi method for instrument development and statewide consensus building.
Main Results:
- Identification of gaps in removable (temporary or permanent) documentation.
- Lack of clear standards for crisis (surge) documentation criteria.
- Understanding of current practices and potential areas for modification in nursing documentation.
Conclusions:
- Findings will inform strategies to improve the value and usability of crisis nursing documentation.
- Policy recommendations are needed to address documentation burden during healthcare crises.
- Optimizing nursing documentation is crucial for enhancing clinician well-being and patient care.
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