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Back to Babies: Reducing Documentation Time in the NICU
Shama Y Patel1,2,3, Rebecca S Rose4, Emily C Webber5
1Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio, United States.
ACI Open
|July 29, 2026
Summary
Implementing a new documentation standard in the neonatal intensive care unit (NICU) improved the timeliness of daily progress notes. This standardized process enhanced efficiency for neonatologists and advanced practice providers (APPs).
Area of Science:
- Neonatal Intensive Care Unit (NICU) care
- Healthcare Informatics
- Clinical Documentation Improvement
Background:
- Lack of standardized best practices for daily progress notes in NICUs.
- Variability in documentation content and completion times.
- Need for improved efficiency in electronic medical record (EMR) workflows.
Purpose of the Study:
- To implement a consistent documentation standard for neonatology providers.
- To improve the timeliness of daily progress note completion.
- To maintain clinician satisfaction and reduce EMR documentation burden.
Main Methods:
- Formed a multidisciplinary workgroup to define ideal documentation content and workflow.
- Conducted baseline assessments including change readiness surveys.
- Sampled and compared progress note completion times pre- and post-intervention over 6 months.
Main Results:
- Mean completion time for progress notes improved significantly from 10 hours 32 minutes to 8 hours 40 minutes (p < 0.01).
- Notes generated by neonatologists were completed earlier than those with an APP and Neonatologist addendum.
- The intervention demonstrated a reduction in documentation time and variability.
Conclusions:
- A standardized documentation process can significantly improve the timeliness of NICU progress notes.
- Specialty-specific education is crucial for successful EMR workflow transitions.
- Standardization efforts can enhance efficiency and potentially clinician satisfaction in NICU documentation.
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