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Keywords

Documentation, Electronic medical records, Nursing, Time study data

 

Authors

  1. YEE, TRACY PhD, MPH
  2. NEEDLEMAN, JACK PhD
  3. PEARSON, MARJORIE PhD, MSHS
  4. PARKERTON, PATRICIA PhD, MPH
  5. PARKERTON, MELISSA MA
  6. WOLSTEIN, JOELLE MA

Abstract

We investigated nurses' time spent in documentation as it relates to the use of electronic charting. A cross-sectional analysis was completed using time and motion data collected during a nursing process improvement initiative for 105 units in 55 hospitals. Ordinary least squares regression with a cluster adjustment revealed very little difference in time spent in documentation with or without the use of electronic medical records or computerized nursing notes. Nurses spent 19% of their time completing documentation, regardless of electronic charting usage, compared with all other categories of care. These findings suggest that integrated electronic medical records and computerized nursing notes do not appear to increase the time nurses spend documenting.