Related Experiment Video
Updated: May 1, 2026
03:47
Author Spotlight: Workflow for Integrating POCUS Data into EHR for Managing Heart Failure Patients
Published on: July 12, 2024
1.3K
Exploring nurses' documentation prioritization strategies to alleviate EHR documentation burden: a phenomenological
Rosemary Mugoya1,2, Jennifer Thate3, Fan Hao2
1Goldfarb School of Nursing, Barnes-Jewish College, BJC HealthCare, St. Louis, MO, 63110, United States.
JAMIA Open
|April 30, 2026
Summary
Nurses prioritize patient care over excessive electronic health record documentation, facing frustration from redundant tasks. Reducing non-value-added documentation can improve patient care and reduce nurse burnout.
Area of Science:
- Nursing
- Health Informatics
- Patient Care
Background:
- The Excessive Documentation Burden (ExDocBurden) in Electronic Health Records (EHRs) significantly impacts inpatient nurses.
- Understanding nurses' prioritization of documentation is crucial for optimizing EHR usability and workflow.
Purpose of the Study:
- To explore inpatient nurses' lived experiences in determining and prioritizing necessary documentation within the context of EHR ExDocBurden.
- To identify factors influencing nurses' documentation prioritization and its impact on patient care.
Main Methods:
- A qualitative phenomenological approach using interpretive phenomenology.
- Purposive sampling of 14 registered nurses from acute and critical care settings.
- Data collection via semi-structured interviews, analyzed using Colaizzi's 7-step and Smith's Interpretive Phenomenology Analysis.
Main Results:
- Nurses prioritize patient care needs above EHR documentation requirements.
- Identified themes include advocating for patient needs, real-time vs. delayed documentation, EHR-driven autonomy erosion, unnecessary/redundant documentation, and fear/pressure in charting.
- Nurses encountered significant unnecessary and redundant documentation, leading to emotional strain and defensive charting.
Conclusions:
- Minimizing non-value-added documentation and empowering nurses' clinical judgment is essential.
- Streamlining EHR documentation can alleviate nurse strain and foster a more patient-centered care approach.
- Supporting nurse-driven documentation practices enhances patient care quality and meets organizational needs.
Related Concept Videos
01:30Methods of Documentation VII: EMR
1.5K
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...
1.5K
01:21Methods of Documentation III: PIE
1.8K
Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care planning. It is a structured approach to organizing patient data based on problems, interventions, and evaluations. Here's a breakdown of its key features and considerations:
1.8K
01:26Guidelines for Nursing Documentation II
2.0K
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.
2.0K
01:30Guidelines for Nursing Documentation I
2.5K
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.
2.5K
01:08Role of Communication in the Nursing Process III: Evaluation and Documentation
2.0K
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:
2.0K
01:10Documentation of Nursing Diagnosis
1.8K
The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters...
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters...
1.8K