Healthc Inform Res.  2016 Oct;22(4):270-276. 10.4258/hir.2016.22.4.270.

Factors Associated with the Timeliness of Electronic Nursing Documentation

• Ahn M
• Choi M
• Kim Y

• KMID: 2357380
• DOI: http://doi.org/10.4258/hir.2016.22.4.270

Abstract

OBJECTIVES
To investigate the factors associated with the timeliness of electronic nursing documentation using the entry time on the Electronic Medical Record (EMR) system.
METHODS
As a retrospective study, data were extracted from January 1 to February 28, 2014 from a hospital EMR system and a nurses' personnel information system. The timeliness of instances of nursing documentation was categorized into "˜timely' or "˜untimely' according to whether the entry time was time-stamped within the working hours during each day, evening, or night shift. Factors associated with the timeliness of the electronic nursing documentation were included in the logistic regression models as nurse- and patient-associated factors.
RESULTS
Among 1,700,247 instances of electronic nursing documentation, 79.3% (n = 1,347,711) were completed within the working hours. Years of nursing experience, nursing shift, days of the week, patients' age, and medical department had a statistically significant associated with the timeliness of nursing records. Nurses with experience of more than 1 year entered nursing records over 2 times more during their working hours than did less experienced nurses. During the evening and night shifts, nurses were 1.49 times and 9.19 times more likely to enter nursing documents in a timely manner, respectively, as compared to those in the day shift.
CONCLUSIONS
Nursing documentation was typically completed outside of working hours when a nurse had little experience, worked during the day shift or weekdays, and when tasks were unpredictable. This shows that new nurses need support to familiarize them with various tasks and the overall workflow.

Keyword

Electronic Health Records; Nursing Process; Nursing Records; Nursing Informatics; Documentation

MeSH Terms

Electronic Health Records
Information Systems
Logistic Models
Nursing Informatics
Nursing Process
Nursing Records
Nursing*
Retrospective Studies

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