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In the spring of 2019, a Midwestern Academic Center embarked on a project to decrease nursing documentation burden in the electronic health record. The results of the project and implementation are presented along with future initiatives to decrease documentation burden.
Key Words: shift assessment, nursing documentation, burden reduction, electronic health record (EHR).
Former President George W. Bush addressed the need for computerized health records in his State of the Union Address in 2004 (Alexander, 2015). Former President Barack Obama enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act as part of the American Recovery and Reinvestment Act, signing it into law in 2009 to promote adoption and meaningful use of health information technology (Florance, 2009). Organizations across the country raced to implement the electronic health record (EHR) and take advantage of the financial incentives. The build design and workflow transition from paper to computerized documentation has led to documentation burden in overlapping domains identified by the American Nursing Informatics Association (ANIA) (2020) in their position paper which includes regulatory, reimbursement, quality, usability, interoperability/standards, and healthcare organization self-imposed documentation requirements for nurses. Many nurses were taught "if it's not documented it's not done" (ANIA, 2020, p. 3). This sacred cow needs to be challenged with adoption of computerized documentation. The EHR was meant to improve patient care and workflow, facilitate communication with improved interoperability, and lead to more efficiency not less.
Documentation is an integral activity for nursing (Russell et al., 2020). The American Nurse Association (ANA) (2010) states, "nursing documentation is to be clear, accurate, and accessible and is essential element of safe, quality, evidence-based nursing practice" (p. 3). ANA's position statement on EHRs (2009) supports patient information collected and recorded accurately and efficiently to promote effective patient communication and decision making. The documentation needs to tell the patient story in a clear and succinct manner.
Documentation is one of the most timeconsuming EHR tasks for nurses and contributes to frustration with the EHR system. Transitioning from paper charting to an EHR system was touted as leading to efficiency in workload and more time for patient care; as well as enhancing and improving healthcare quality and patient safety. Many documentation requirements were developed before the EHR era and have not been...