Date of Doctor of Nursing Practice Project Completion

Spring 2026

Faculty Advisor

Dr. Linda Cole

Abstract

Purpose: This quality improvement project aimed to increase documentation efficiency in a multidisciplinary stroke clinic through implementation of standardized neurological note templates within the electronic medical record (EMR) system.

Background: EMR documentation is essential for safe and coordinated patient care, but can be time-consuming for healthcare providers. Neurological documentation requires detailed clinical information, contributing to increased documentation burden. At the multidisciplinary stroke clinic, providers reported spending significant time on documentation, with some notes finalized up to 48 hours after patient encounters.

Methodology: Standardized neurological note templates were developed with provider input. Documentation efficiency metrics included note completion time, proportion of notes completed within working hours, “pajama time”, and template compliance. Provider satisfaction was assessed using the Mini Z survey. A retrospective chart review was conducted to collect pre-implementation baseline study data between September 2024 – September 2025. Post-implementation data was collected prospectively between September – November 2025. Project implementation was guided by the Plan–Do–Study–Act (PDSA) framework. Pre- and post-implementation data were compared using descriptive analysis.

Results: Average time to note completion decreased by 32.5 minutes (50.1 to 17.6 min; 64.8%). The proportion of notes completed during working hours increased from 20% to 91%, and pajama time decreased by 95%. Template compliance remained at 100%. Mini Z results showed a 42% improvement in the work pace and EMR-related stress subscale 2.

Implications: Standardized neurological note templates provide a practical approach to improving documentation efficiency and provider satisfaction. Future research should examine strategies to sustain long-term use across providers and specialties.

Keywords

Electronic medical record, documentation efficiency, note templates

Included in

Nursing Commons

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