1. Englebright, Jane PhD, RN, CENP, FAAN
  2. Michel, Sarah MBA, BSN, RN, NE-BC
  3. Boyd, David L. DNP, RN, CNS, RN-BC
  4. Hulett, Shannon L. DNP, RN, CNL


A focused effort is needed to capture the utility and usability of the electronic health record for providing usable and reusable data while reducing documentation burden. A collaborative effort of nurse leaders and experts was able to generate national consensus recommendations on documentation elements related to admission history. The process used in this effort is summarized in a framework that can be used by other groups to develop content that reduces documentation burden while maximizing the creation of usable and reusable data.