Highlights
- •Admission workflows consume a significant amount of nurses' time.
- •Pediatric essential clinical dataset (ECD) is a nursing documentation intervention.
- •A Pediatric ECD can influence nurses' documentation efficiencies and satisfaction.
Abstract
Purpose
The purpose of this study was to improve nursing documentation efficiencies and satisfaction
of a pediatric admission history workflow. Secondary aims determined if defining essential
data elements was associated with decreased pediatric admission history documentation
time, increased dataset completion rate, and increased satisfaction.
Design and methods
A quasi-experimental between-group difference comparison was conducted for a nurse-led
quality improvement study that included implementation of a pediatric essential clinical
dataset (ECD) tool for pre/post-intervention analysis of nursing admission history
documentation time, dataset completion rate, and satisfaction. A survey was administered
to nurses pre- and post-intervention to compare documentation satisfaction.
Results
Nursing admission history documentation time decreased by 1 min 31 s and the number
of clicks decreased 38%. Dataset utilization increased 8% indicating improved nursing
documentation of essential questions within a pediatric admission history form. Nursing
documentation satisfaction with the pediatric admission history form was minimally
impacted by the pediatric ECD study intervention.
Conclusions
Defining what is essential for nurses to document positively influenced nursing documentation
time, dataset completion rate, and satisfaction.
Practice implications
The study contributed to EHR content standardization, optimization, and documentation
efficiencies for nurses within a pediatric organization with implications for clinical
and informatics collaboration to create real-world evidence, leveraging an intervention
that decreased documentation burden and increased time for children and families.
Keywords
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Article info
Publication history
Published online: April 09, 2021
Accepted:
March 22,
2021
Received in revised form:
March 18,
2021
Received:
December 17,
2020
Identification
Copyright
© 2021 Elsevier Inc. All rights reserved.
