Relationship between Additional Required Nursing Documentation and Patient Outcomes: A Scoping Review

Area of Science:

• Nursing Informatics
• Healthcare Quality Improvement
• Evidence-Based Practice

Background:

• Nursing documentation serves essential roles in clinical communication and care coordination.
• Additional documentation requirements are often implemented for compliance and secondary uses, potentially increasing nurse burden.
• A gap exists in understanding the direct impact of increased required nursing documentation on patient outcomes.

Purpose of the Study:

• To synthesize and describe the current evidence on the relationship between added required electronic nursing documentation and improved patient outcomes.
• To assess the quality of existing research in this area within inpatient hospital settings.

Main Methods:

• A comprehensive literature search was conducted across major databases (PubMed, CINAHL, Web of Science, Embase) from January 2011 to May 2023.
• Studies were screened for relevance to additional required nursing documentation and patient outcomes.
• Two authors independently reviewed titles, abstracts, and full texts based on eligibility criteria.

Main Results:

• Of 47 included studies, 57.4% focused solely on process measures (e.g., compliance), while 42.6% included patient outcome measures (e.g., infection rates, length of stay).
• Only 45% of studies that included patient outcomes reported a statistically significant positive relationship.
• The overall quality of evidence was low, with a majority being quality improvement studies and only one randomized controlled trial.

Conclusions:

• The assumed link between increased required nursing documentation and better patient outcomes is not supported by high-quality empirical evidence.
• The limited number of significant findings and methodological weaknesses highlight the need to critically examine documentation practices.
• Focus should shift towards identifying documentation that genuinely benefits patients rather than solely increasing administrative burden.