Nursing Documentation Variation Across Different Medical Facilities Within an Integrated Healthcare System
Open accessAbstract
The purpose of this study was to demonstrate nursing documentation variation based on electronic health record design and its relationship with different levels of care by reviewing how various flowsheet measures, within the same electronic health record across an integrated healthcare system, are documented in different types of medical facilities. Flowsheet data with information on patients who were admitted to academic medical centers, community hospitals, and rehabilitation centers were used to calculate the frequency of flowsheet entries documented. We then compared the distinct flowsheet measures documented in five flowsheet templates across the different facilities. We observed that each type of healthcare facility appeared to have distinct clinical care foci and flowsheet measures documented differed within the same template based on facility type. Designing flowsheets tailored to study settings can meet the needs of end users and increase documentation efficiency by reducing time spent on unrelated flowsheet measures. Furthermore, this process can save nurses time for direct patient care.
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The distinct distribution might reflect different nursing workflow and documentation patterns across care units.
“This might reflect different nursing workflow and documentation patterns across care units.49”
From Electronic health record system use and documentation burden of acute and critical care nurse clinicians: a mixed-methods study (2024) · cites this paper as [49]
The Discussion reports that nursing documentation differed across facility types and links those differences to patient-care workflows. The study compares academic medical centers, community hospitals, and rehabilitation centers, not documentation patterns across care units within a facility, so the claim changes the setting of the comparison. (LLM, conf=0.83)
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- Authors
- Kang, M.-J., Rossetti, S. C., Knaplund, C., Chang, F. Y., Schnock, K. O., Whalen, K., Gesner, E. J., Garcia, J. P., Cato, K. D., & Dykes, P. C.
- Affiliations
- University of Massachusetts Dartmouth (US)
- Columbia University (US)
- Brigham and Women's Hospital (US)
- Massachusetts General Hospital (US)
- Cape Cod Community College (US)
- ORCID
- Venue
- CIN: Computers, Informatics, Nursing
- Published
- 2021-05-03
- Volume
- 39
- Issue
- 12
- Pages
- 845-850
- ISSN
- 1538-2931 (ISSN-L)
- 1538-9774
- PMC
- PMC8720562
- OpenAlex
- W3157926389
- Cited by
- 13
- References
- 15
- Citations by year
- 2026: 2 · 2025: 2 · 2024: 6 · 2023: 2 · 2022: 1
- FWCI
- 4.65
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- CIN Computers Informatics Nursing (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Nursing Research (R01NR016941)
- Topics
- Health Sciences › Nursing › Issues, ethics and legal aspects › Nursing Diagnosis and Documentation
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
- Keywords
- nursing documentation, electronic health records, flowsheet design, integrated health system, academic medical centers, community hospitals, rehabilitation centers, documentation efficiency, nursing workload
- MeSH terms
- Documentation, Humans, Nursing Care, Nursing Records, Delivery of Health Care, Integrated, Electronic Health Records
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