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Improving Nurse Documentation Time via an Electronic Health Record Documentation Efficiency Tool
John Will1, Deborah Jacques1, Denise Dauterman1
1MCIT Department of Health Informatics, New York University Langone Health, New York, New York, United States.
Applied Clinical Informatics
|April 11, 2025
Summary
Flowsheet macros significantly reduced nurses' time in electronic health records (EHR) and documentation activities. However, time savings varied across departments, indicating potential limitations for certain patient populations.
Area of Science:
- Healthcare Informatics
- Nursing Practice
- Health Services Research
Background:
- Nursing documentation burden is a significant concern in the US healthcare system.
- Electronic Health Record (EHR) documentation contributes to this perceived burden.
- Flowsheet macros are efficiency tools designed to alleviate documentation workload.
Purpose of the Study:
- To evaluate the impact of flowsheet macros on reducing nursing time spent in documentation and the EHR.
- To determine if a single-click documentation tool can improve efficiency.
Main Methods:
- Nurses were encouraged to use flowsheet macros within the EHR.
- Data on flowsheet documentation time and overall system time were extracted for nurses' shifts.
- Linear regression analysis was used to assess the relationship between macro utilization and time spent.
Main Results:
- Flowsheet macro use showed a significant negative relationship with time spent in flowsheets (AOR = -0.291, p < 0.001).
- Flowsheet macro use also had a significant negative relationship with overall EHR time (AOR = -0.269, p < 0.001).
- Time savings were observed in medical-surgical, critical care, and obstetrics units, but not in emergency or rehabilitation units.
Conclusions:
- Flowsheet macros utilization is associated with decreased time spent by nurses in both flowsheets and the EHR.
- The effectiveness and time savings of flowsheet macros vary by department, suggesting limited applicability in some settings.
- Further research is needed to explore if these time savings translate to reduced nurse documentation burden.
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