Date of Doctor of Nursing Practice Project Completion
Summer 5-31-2025
Faculty Advisor
Dr. Debbie Cline
Abstract
Purpose: The purpose of this quality improvement project was the reduction of electronic health record (EHR) documentation time and improve nurse satisfaction in an Intermediate Care Unit (IMU).
Introduction: Nursing documentation supports patient safety, interdisciplinary communication, and regulatory compliance. However, excessive documentation requirements may reduce the time nurses spend with patients, increase the risk of errors, and contribute to job dissatisfaction and burnout. At a large, academic hospital, nurses in the target unit were averaging 155 minutes of documentation per 12-hour shift, ranking in the 90th percentile for documentation time among peer institutions.
Methodology: The project, conducted between March 1 and May 31, 2025, utilized Plan-Do-Study-Act (PDSA) model. A multidisciplinary workgroup identified the interventions, including the development and implementation of a documentation guide to support streamlined documentation.
Results: Average documentation time decreased from 6.4 to 6.2 mins/hr in a 12-hour shift. Average EHR workload dropped from 12.7 to 12.5 mins/hr. Although modest, reductions indicated preliminary improvements. Nurse satisfaction survey results indicated a positive shift in perceptions of documentation practices. Nurses reported improved views of how documentation supports efficiency and productivity, with scores increasing from 3.33 to 3.80 on a 1–5 Likert scale. Additionally, the understanding of assessment documentation requirements strengthened, rising from 4.25 to 4.40 on the same scale.
Implications for Practice: While the documentation time reduction was limited, the project identified actionable areas for EHR optimization and laid groundwork for future improvements. This project highlights the importance of targeted documentation interventions in enhancing workflow efficiency and supporting nurse satisfaction
Keywords
electronic health record, nursing documentation, reduction, intermediate care unit, workload
Recommended Citation
Herbert Rolito C. Ortiz, "Evidence Based Pilot Project To Reduce Nurse Documentation Time in the Electronic Health Record" (2025). Doctor of Nursing Practice Final Project Abstract. 139.
https://digitalcommons.library.tmc.edu/dnp_abstract/139