Related Experiment Video
Updated: May 9, 2025
10:07
Using Learning Outcome Measures to assess Doctoral Nursing Education
Published on: June 21, 2010
18.9K
Evaluating Nurses' Perceptions of Documentation in the Electronic Health Record: Multimethod Analysis
Deborah Jacques1, John Will1, Denise Dauterman1
1Department of Health Informatics, Medical Center Information Technology, NYU Langone Health, One Park Avenue, 12 Fl., New York, NY, 10016, United States, 1 646-784-1726.
JMIR Nursing
|April 28, 2025
Summary
Redesigned electronic health records (EHR) show promise in improving nursing workflows and satisfaction. Further optimization is needed to reduce documentation burdens and enhance usability for better patient care.
Area of Science:
- Nursing Informatics
- Health Information Technology
- Human-Computer Interaction
Background:
- Nurses extensively use electronic health record (EHR) systems for patient care and workflows.
- Redesigning nursing documentation in EHRs may decrease time spent and increase nurse satisfaction.
Purpose of the Study:
- Assess nurses' perceptions of a redesigned EHR system.
- Evaluate the impact of documentation interventions on nursing practice.
- Identify areas for future EHR system improvements.
Main Methods:
- A multimethod project guided by the American Nursing Informatics Association's Six Domains of Burden framework.
- Qualitative focus groups with registered nurses, analyzed thematically.
- Quantitative analysis of EHR vendor time data for documentation duration.
Main Results:
- Six themes emerged: positive feedback, usability, workflow, training, communication, and time spent.
- Nurses reported positive experiences and that the EHR supported patient care.
- Average time spent in flowsheets was 31.11% per 12-hour shift.
Conclusions:
- Opportunities exist to reduce documentation redundancies and improve EHR usability.
- Continuous learning programs and optimized tools, like the oral health assessment, are recommended.
- Incorporating frontline nursing perspectives is crucial for EHR workflow redesign and nurse satisfaction.
More Related Videos
Related Concept Videos
01:30Methods of Documentation VII: EMR
768
Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...
768
01:08Role of Communication in the Nursing Process III: Evaluation and Documentation
1.2K
A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:
1.2K
01:06Legal Guidelines for Documentation
1.2K
The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
1.2K
01:30Guidelines for Nursing Documentation I
932
Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
932
01:20Introduction to Documentation and Reporting
1.4K
Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
1.4K
01:26Guidelines for Nursing Documentation II
943
Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
943