JMIR Publications

ABSTRACT

Background:

Documentation tasks comprise a large percentage of nurses’ workloads. Part of the nursing records were based on a report from the patient. However, it is not a verbatim transcription of the patient's complaints but a type of medical record. Therefore, to reduce the time spent on nursing documentation, it is necessary to assist in the appropriate conversion or citation of patient reports to professional records. However, few studies have been conducted on systems for capturing patient reports in electronic medical records (EMR). In addition, there have been no reports on whether such a system reduces the time spent on nursing documentation.

Objective:

This study aims to develop a patient self-reporting system that appropriately converts data to nursing records and evaluate its effect on reducing the documenting burden for nurses.

Methods:

An electronic medical record-connected questionnaire and a preadmission nursing questionnaire were administered. The questionnaire responses entered by the patients were quoted in the patient profile for inpatient assessment in the nursing system. To clarify its efficacy, the study examined whether the use of the electronic questionnaire system saved nurses’ time entering the patient profile admitted between August and December 2022. It also surveyed the usability of the electronic questionnaire between April and December 2022.

Results:

In the usability survey, 78% of patients answered an electronic questionnaire. Of these, 88% felt it was easy to use, and 85% were willing to use it again. An electronic questionnaire was used in 1,326 of 2,425 admission cases (use group). The Input Time for the patient profile was significantly shorter in the use group than in the no-use group (P<.001). Stratified analysis showed that in the internal medicine wards, nurses took 18% less time to enter patient profiles within the use group (P<.001), even though there was no difference in the amount of information. In contrast, in the surgical wards, there was no difference in the time to entry (P=.50), but there was a greater amount of information in the use group.

Conclusions:

The study developed and implemented a system in which self-reported patient data were captured in the hospital information network and quoted in the nursing system. This system contributes to improving the efficiency of nurses’ task recordings.