Nursing documentation time during implementation of an electronic medical record.
OBJECTIVE
To determine, within the context of all nursing duties, the amount of time nurses spend on documentation during the implementation of an electronic medical record (EMR) on an intrapartum unit.


BACKGROUND
Increased documentation needs during EMR implementation may necessitate increased staffing requirements in an already labor-intensive and demanding environment.


METHODS
A work-sampling study was conducted over a 14-day study period, and 18 of 84 (21%) potential 4-hour observation periods were selected. During each period, a single observer made 120 observations and, on locating a specific nurse, immediately recorded that nurse's activity on a standardized and validated instrument. Categories of nursing activities included documentation, bedside care, bedside supportive care, nonbedside care, and nonpatient care.


RESULTS
A total of 2160 observations were made. The total percentage of nursing time spent for documentation was 15.8%, 10.6% on paper and 5.2% on the computer. The percentage of time spent on documentation was independently associated with day versus night shifts (19.2% vs 12.4%, respectively).


CONCLUSIONS
Despite charting concurrently on both paper and computer, the amount of time spent on documentation was not excessive, and was consistent with previous studies in which neither electronic nor "double charting" occurred.
Korst
Lisa M
LM
Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center Burns Allen Research Institute and University of California, School of Medicine, Los Angeles, CA, USA. ekorst@chla.usc.edu
Eusebio-Angeja
Alea C
AC
Chamorro
Terry
T
Aydin
Carolyn E
CE
Gregory
Kimberly D
KD
D004282:Documentation / Q000379:methods / Q000706:statistics & numerical data*; D017598:Efficiency, Organizational; D006742:Hospital Bed Capacity / Q000706:statistics & numerical data; D006751:Hospital Information Systems / Q000706:statistics & numerical data; D006764:Hospitals, Community; D006785:Hospitals, University; D006801:Humans; D015141:Los Angeles; D016347:Medical Records Systems, Computerized / Q000706:statistics & numerical data*; D024802:Nurse's Role; D009732:Nursing Care / Q000458:organization & administration; D015403:Nursing Evaluation Research; D009737:Nursing Records / Q000706:statistics & numerical data*; D009741:Nursing Staff, Hospital / Q000706:statistics & numerical data / Q000600:supply & distribution; D009773:Obstetric Nursing / Q000458:organization & administration; D016017:Odds Ratio; D013647:Task Performance and Analysis; D013997:Time Factors; D016526:Workload / Q000706:statistics & numerical data*