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Appl Clin Inform 2025; 16(04): 796-803
DOI: 10.1055/a-2581-6172
Special Topic on Reducing Technology-Related Stress and Burnout

Improving Nurse Documentation Time via an Electronic Health Record Documentation Efficiency Tool

John Will
1   MCIT Department of Health Informatics, New York University Langone Health, New York, New York, United States
,
Deborah Jacques
1   MCIT Department of Health Informatics, New York University Langone Health, New York, New York, United States
,
Denise Dauterman
1   MCIT Department of Health Informatics, New York University Langone Health, New York, New York, United States
,
Rachelle Torres
1   MCIT Department of Health Informatics, New York University Langone Health, New York, New York, United States
,
Glenn Doty
1   MCIT Department of Health Informatics, New York University Langone Health, New York, New York, United States
,
Kerry O'Brien
1   MCIT Department of Health Informatics, New York University Langone Health, New York, New York, United States
,
Lisa Groom
1   MCIT Department of Health Informatics, New York University Langone Health, New York, New York, United States
2   Department of Population Health, Grossman School of Medicine, New York University, New York, New York, United States
› Author Affiliations
Funding None.
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Abstract

Background

Nursing documentation burden is a growing point of concern in the United States health care system. Documentation in the electronic health record (EHR) is a contributor to perceptions of burden. Efficiency tools like flowsheet macros are one development intended to ease the burden of documentation.

Objective

This study aimed to evaluate whether flowsheet macros, a documentation efficiency tool in the EHR that consolidates documentation into a single click, reduces the time spent on documentation activities and the EHR overall.

Methods

Nurses in the health system were encouraged to create and utilize flowsheet macros for their documentation. Flowsheet documentation and time in system data for nurses' first and last shifts in the evaluation period were extracted from the EHR. Linear regression with control variables was utilized to understand if the utilization of flowsheet macros for documentation reduced the time spent in flowsheets or the EHR.

Results

The results of linear regression showed a significant, negative relationship between flowsheet macros use and time in flowsheets (adjusted odds ratio [AOR] = −0.291, 95% confidence interval [CI] = −0.342 to −0.240, p < 0.001). Flowsheet macros use and time in system also had a significant, negative relationship (AOR = −0.269, CI = −0.390 to −0.147, p ≤ 0.001). Subgroups for department specialties showed time savings in flowsheet activities for medical surgical, critical care, and obstetrics units, however, a significant relationship was not found in emergency and rehabilitation units.

Conclusion

Utilization of flowsheet macros was associated with a decrease in the amount of time a nurse spends in both flowsheets and the EHR. Adoption and timesavings varied by the department setting, suggesting flowsheet macros may not be applicable to all patient types or conditions. Future research should investigate if the time savings from this tool yield benefits in perceptions of nurse documentation burden.

Keywords

nursing - documentation burden - electronic health record - efficiency

Protection of Human and Animal Subjects

Because the quality improvement project dataset was limited and project subjects could not be identified, it was not considered human subjects research and did not necessitate review by the AHS IRB.




Publication History

Received: 04 December 2024

Accepted: 10 April 2025

Accepted Manuscript online:
11 April 2025

Article published online:
22 August 2025

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