Abstract
Objective
This study aimed to explore: (1) how nurses in the acute care setting describe their
experience(s) of excessive documentation burden (ExDocBurden); (2) what factors contribute
to ExDocBurden for nurses in the inpatient setting; and (3) nurses' perspectives on
solutions to mitigate ExDocBurden that support documentation practices that they deem
essential to providing safe, high-quality care.
Methods
Semistructured interviews were conducted with 18 acute care nurses. Transcribed interviews
were analyzed using the constant comparative method.
Results
All sources of ExDocBurden were categorized as issues of usability which included
four themes: (1) inaccurate data resulting from EHR rules or logic that force or limit
responses; (2) burdensome lengthy flowsheets—scrolling, clicking, and searching for
the right place to document; (3) checking the box prevents meaningful information
capture; and (4) a moving target—ongoing updates and inadequate training. Strategies
to reduce ExDocBurden were categorized as “current approaches” and “future innovations.”
Discussion
Based on synthesis of categories and themes, alongside existing literature, we propose
the following recommendations: (1) develop evidence-based consensus on essential EHR
data elements, (2) minimize structured data entry interfaces and maximize forms of
data entry that develop and reflect nurses' clinical reasoning, (4) leverage emerging
technologies to capture and parse data into structured formats suitable for secondary
uses.
Conclusion
Addressing usability issues identified by nurses is critical to reducing ExDocBurden.
Increasing required data entry in structured flowsheets not only contributes to ExDocBurden,
but also leads to inaccurate data capture that has serious implications for AI tools
that rely on the quality of previously documented data.
Keywords
electronic health record - excessive documentation burden - nursing documentation
