EHR Documentation Frequency Changes Across the COVID-19 Pandemic

Presentation Time: 04:00 PM - 04:15 PM

Abstract Keywords: Documentation Burden, Nursing Informatics, Data Mining
Primary Track: Applications
Programmatic Theme: Clinical Informatics

Documentation is a critical bridge between clinicians’ workflows and direct patient care and requires a delicate balance between maintaining regulatory requirements and prioritizing patient needs. The documentation relaxation policies during the COVID-19 pandemic provide an opportunity to explore nurses’ documentation practices and what factors contributed to their documentation decisions. We explored the documentation trends of 10 flowsheet measure groups based on the measure names’ clinical semantics grouped by large language models. The study’s time period included the COVID-19 pandemic and before and after the implementation of a documentation relaxation policy, Surge Documentation. We established a pipeline to build regression models and visualizations for the documentation frequency trend changes. Documentation rates increased during COVID-19 and were significantly reduced with the implementation of documentation relaxation policies. We identified workload acuity-related factors, such as unit-level order sum, as contributing to more documentation. In this study, we also demonstrated that nurses engaged their critical thinking to prioritize documentation based on their workload and patient acuity. Further documentation policies should support nursing critical thinking and expertise in prioritizing nursing activities and patient care.

Speaker(s):
Hao Fan, MD
Washington University School of Medicine in St Louis

Author(s):
Hao Fan, MD - Washington University School of Medicine in St Louis; Sarah Rossetti, RN, PhD - Columbia University Department of Biomedical Informatics; Rosie Mugoya, Bsn - Goldfarb School of Nursing and Washington University of St. Louis; Haomiao Jia, PhD - Columbia University Medical Center; Jennifer Thate, PhD, CNE, RN - Siena College; Amy Finnegan, PhD, MPA - Columbia University Medical Center; IntraHealth International; Albert Lai, PhD, FACMI, FAMIA - Washington University; Kenrick Cato, PhD, RN, CPHIMS, FAAN - University of Pennsylvania/ Children's Hospital of Philadelphia; Po-Yin Yen, PhD, RN, FAMIA, FAAN - Washington University in St. Louis;