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The nursing shared governance clinical informatics and technology council identified that nursing admission documentation was particularly cumbersome and time consuming. The group established four guiding principles used to judge if the assessment field added value. The review resulted in a six percent reduction in the number of fields. Future activities will apply the guiding principles to other documentation sections alleviating additional documentation burden.
Key Words: Documentation burden, cognitive burden, electronic health record (EHR), evidence-based clinical documentation (EBCD), clinician well-being.
Documentation is an integral activity of clinician activities. Clinical records traditionally were hand-written notes entered in chronological order using incomplete sentences to convey salient features of patient stories. These records captured clinician's findings, goals, outcomes, and plans. The level of effort to produce the documentation was low and the information highly valued for support of clinical problem diagnosis and interprofessional communication. Fast forward to today, users describe current electronic documentation practices as burdensome data collection activities (Horvath et al., 2018; Ommaya et al., 2018) that ineffectively support understanding the patient story. The current documentation includes data beyond the original intent and is used for nonclinical purposes such as billing, regulatory, legal, and self-imposed artifact capture - where someone requests additional data points be collected as a method to monitor or control user behavior. Several publications report the growing issues of documentation burden with negative impact on clinicians (Ashton, 2018; Golob et al., 2016; Joukes et al., 2018; Leventhal, 2015; Mosier & Englebright, 2019; Shanafelt et al., 2016; Topaz et. al. 2017). The National Academy of Medicine explores this issue in a discussion paper examining clinician burnout secondary to tasks that are non-value added to patient care and irrelevant to the clinician's profession (Ommaya et al., 2018). In response to this issue, which was raised by the membership of the Clinical Informatics Technology Council (CLINTEC), an evaluation of the nursing admission assessment was conducted with the objective to return to evidence-based data capture that supports nursing practice.
Background
The American Nurses Association (ANA) (2010) states nursing documentation is to be clear, accurate, accessible, and is essential to support evidence-based practice and quality outcomes. Furthermore, ANA (2010) lists documentation of nurses' work as critical for effective communication with other disciplines, regardless of the acknowledgment that nurses view...