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Accepted for/Published in: JMIR Nursing

Date Submitted: Dec 4, 2024
Date Accepted: Mar 22, 2025

The final, peer-reviewed published version of this preprint can be found here:

Evaluating Nurses’ Perceptions of Documentation in the Electronic Health Record: Multimethod Analysis

Jacques D, Will J, Dauterman D, Zavotsky K, Delmore B, Doty G, O'Brien K, Groom L

Evaluating Nurses’ Perceptions of Documentation in the Electronic Health Record: Multimethod Analysis

JMIR Nursing 2025;8:e69651

DOI: 10.2196/69651

PMID: 40294588

PMCID: 12052386

Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.

Exploring Nursing Perception of Documentation in the Electronic Health Record

  • Deborah Jacques; 
  • John Will; 
  • Denise Dauterman; 
  • Kathleen Zavotsky; 
  • Barbara Delmore; 
  • Glenn Doty; 
  • Kerry O'Brien; 
  • Lisa Groom

ABSTRACT

Background:

Nurses represent the largest group of users within the electronic health record (EHR) system, relying on its tools to support patient care and nursing workflow. Recent studies suggest that redesigning nursing documentation can reduce time in the EHR system and improve nurse satisfaction.

Objective:

This quality improvement project evaluated nursing documentation perception related to the (EHR), assess the impact of documentation improvement interventions, and identify barriers to develop new strategies to support documentation workflows.

Methods:

This quality improvement project evaluated nursing documentation perception related to the (EHR), assess the impact of documentation improvement interventions, and identify barriers to develop new strategies to support documentation workflows.

Results:

Twenty registered nurses participated in the focus group discussions. 88.27% of participants had >3 years of EHR experience at the AHS, and 94.11% reported being competent or above in the EHR system. Six themes emerged: positive feedback, usability and workflow opportunities, nuisance, training and education, communication, and time in system. EHR vendor time data revealed time in flowsheets averaged 30.28% per 12-hour shift.

Conclusions:

Frontline nursing perspectives in the restructuring of EHR workflows is imperative in identifying interventions to support EHR satisfaction.


 Citation

Please cite as:

Jacques D, Will J, Dauterman D, Zavotsky K, Delmore B, Doty G, O'Brien K, Groom L

Evaluating Nurses’ Perceptions of Documentation in the Electronic Health Record: Multimethod Analysis

JMIR Nursing 2025;8:e69651

DOI: 10.2196/69651

PMID: 40294588

PMCID: 12052386

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