Use of Electronic Health Record Documentation by Healthcare Workers in an Acute Care Hospital System/PRACTITIONER APPLICATION

Acute care clinicians spend significant time documenting patient care information in electronic health records (EHRs). The documentation is required for many reasons, the most important being to ensure continuity of care. This study examined what information is used by clinicians, how this informati...

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Bibliographic Details
Published inJournal of healthcare management Vol. 59; no. 2; p. 130
Main Authors Penoyer, Daleen Aragon, Cortelyou-Ward, Kendall H, Noblin, Alice M, Bullard, Tim, Talbert, Steve, Wilson, Jason, Schafhauser, Beatrice, Briscoe, Joshua G, Shaw, Gene
Format Journal Article
LanguageEnglish
Published Chicago Lippincott Williams & Wilkins Ovid Technologies 01.03.2014
Subjects
Best practice
Caregivers
Communication
Decision making
Document management
Documentation
Efficiency
Electronic health records
Emergency medical care
Hospital systems
Hospitals
Nurses
Nursing care
Patients
Physicians
Studies
United States > US
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Summary:Acute care clinicians spend significant time documenting patient care information in electronic health records (EHRs). The documentation is required for many reasons, the most important being to ensure continuity of care. This study examined what information is used by clinicians, how this information is used for patient care, and the amount of time clinicians perceive they review and document information in the EHR. A survey administered at a large, multisite healthcare system was used to gather this information. Findings show that diagnostic results and physician documents are viewed more often than documentation by nurses and ancillary caregivers. Most clinicians use the information in the EHR to understand the patient's overall condition, make clinical decisions, and communicate with other caregivers. The majority of respondents reported they spend 1 to 2 hours per day reviewing information and 2 to 4 hours documenting in the EHR. Bedside nurses spend 4 hours per day documenting, with much of this time spent completing detailed forms seldom viewed by others. Various flow sheets and forms within the EHR are rarely viewed. Organizations should provide ongoing education and awareness training for hospital clinical staff on available forms and best practices for effective and efficient documentation. New forms and input fields should be added sparingly and in collaboration with informatics staff and clinical team members to determine the most useful information when developing documentation systems. [PUBLICATION ABSTRACT]
ISSN:1096-9012
1944-7396