Completion of electronic nursing documentation of inpatient admission assessment: insights from Australian metropolitan hospitals

Abstract

INTRODUCTION: Electronic nursing documentation is an essential aspect of inpatient care and multidisciplinary communication. Analysing data in electronic medical record (eMR) systems can assist in understanding clinical workflows, improving care quality, and promoting efficiency in the healthcare system. This study aims to assess timeliness of completion of an electronic nursing admission assessment form and identify patient and facility factors associated with form completion in three metropolitan hospitals. MATERIALS AND METHODS: Records of 37,512 adult inpatient admissions (November 2018-November 2019) were extracted from the hospitals eMR system. A dichotomous variable descriptive of completion of the nursing assessment form (Yes/No) was created. Timeliness of form completion was calculated as the interval between date and time of admission and form completion. Univariate and multivariate multilevel logistic regression were used to identify factors associated with form completion. RESULTS: An admission assessment form was completed for 78.4% (n=29,421) of inpatient admissions. Of those, 78% (n=22,953) were completed within the first 24 hours of admission, 13.3% (n=3,910) between 24-72 hours from admission, and 8.7% (n=2558) beyond 72 hours from admission. Patient length of hospital stay, admission time, and admitting units nursing hours per patient day were associated with form completion. Patient gender, age, and admitting unit type were not associated with form completion. DISCUSSION: Form completion rate was high, though more emphasis needs to be placed on the importance of timely completion to allow for adequate patient care planning. Staff education, qualitative understanding of delayed form completion, and streamlined guidelines on nursing admission and eMR use are recommended.

Improving the Quality of Electronic Medical Record Documentation: Development of a Compliance and Quality Program

“…This also fills a gap previously identified in Australian research on EMR admission documentation. 16 Positive responses from clinicians receiving in-person and personalized EMR support are in agreement with previous literature that showed EMR demonstrations improved multidisciplinary clinicians' attitudes and knowledge. 17 Additionally, reassessment of the EMR system, as well as targeted interventions based on the audit results, supports the need to consider that clinical documentation information is not only valued by clinicians but integral to support them in providing safe and quality patient care.…”