Thieme E-Journals - Applied Clinical Informatics / Full Text
21 November 2019 18 May 2020Publication Date:08 July 2020 (online) Background Documentation burden, defined as the need to complete unnecessary documentation elements in the electronic health record (EHR), is significant for nurses and contributes to decreased time with patients as well as burnout. Burden increases when new documentation elements are added, but unnecessary elements are not systematically identified and removed. Objectives Reducing the burden of nursing documentation during the inpatient admission process was a key objective for a group of nurse experts who collaboratively identified essential clinical data elements to be documented by nurses in the EHR. Methods Twelve health care organizations used a data-driven process to evaluate inpatient admission assessment data elements to identify which elements were consistently deemed essential to patient care. Processes used for the twelve organizations to reach consensus included identifying: (1) data eleme