EHR Documentation Frequency Changes Across the COVID-19 Pandemic.

Area of Science:

• Healthcare Administration
• Nursing Informatics
• Clinical Documentation

Background:

• The documentation burden in healthcare is significant, raising questions about its clinical value.
• The COVID-19 pandemic intensified patient care demands and led to policy changes impacting clinical documentation.

Purpose of the Study:

• To analyze nurses' documentation patterns during the COVID-19 pandemic.
• To examine the impact of increased patient care demands and a documentation relaxation policy on documentation frequency.

Main Methods:

• Trend analysis of documentation frequency over time.
• Segmented regression and mixed-effect Poisson regression were used to analyze trend changes.
• Data collected from a Midwest academic medical center during the pandemic and policy implementation.

Main Results:

• Documentation frequency increased in response to heightened patient care demands during the pandemic.
• A significant decrease in documentation frequency was observed following the implementation of the Surge Documentation policy.
• Reductions in documentation were most notable in flowsheets not directly related to patient acuity.

Conclusions:

• Nurses demonstrated critical thinking by prioritizing documentation based on patient care needs.
• Future policies should empower nurses with autonomy in documentation practices.
• Policies should avoid imposing excessive and potentially non-essential documentation requirements.