Client Relationships: Clinical Leadership Team, Cerner Corp, Kansas City, Missouri, United States.
Department of Clinical Informatics, Northern Light Health, Brewer, Maine, United States.
Appl Clin Inform. 2020 May;11(3):464-473. doi: 10.1055/s-0040-1713634. Epub 2020 Jul 8.
Documentation burden, defined as the need to complete unnecessary documentation elements in the electronic health record (EHR), is significant for nurses and contributes to decreased time with patients as well as burnout. Burden increases when new documentation elements are added, but unnecessary elements are not systematically identified and removed.
Reducing the burden of nursing documentation during the inpatient admission process was a key objective for a group of nurse experts who collaboratively identified essential clinical data elements to be documented by nurses in the EHR.
Twelve health care organizations used a data-driven process to evaluate inpatient admission assessment data elements to identify which elements were consistently deemed essential to patient care. Processes used for the twelve organizations to reach consensus included identifying: (1) data elements that were truly essential, (2) which data elements were explicitly required during the admission process, and (3) data elements that must be documented by a registered nurse (RN).
The result was an Admission Patient History Essential Clinical Dataset (APH ECD) that reduced the amount of admission documentation content by an average of 48.5%. Early adopters experienced an average reduction of more than two minutes per admission history documentation session and an average reduction in clicks of more than 30%.
The creation of the essential clinical dataset is an example of combining evidence from nursing practice within the EHR with a set of predefined guiding principles to decrease documentation burden for nurses. Establishing essential documentation components for the adult admission history and intake process ensures the efficient use of bedside nurses' time by collecting the right (necessary) information collected by the right person at the right time during the patient's hospital stay. Determining essential elements also provides a framework for mapping components to national standards to facilitate shareable and comparable nursing data.
在电子健康记录（EHR）中完成不必要的文档元素的文档编制负担对于护士来说是一个重大问题，这会导致与患者相处的时间减少以及职业倦怠。当添加新的文档元素时，负担会增加，但没有系统地识别和删除不必要的元素。
减少住院患者入院过程中的护理文档编制负担是一组护士专家的主要目标，他们共同确定了护士在 EHR 中需要记录的基本临床数据元素。
十二个医疗机构使用数据驱动的过程来评估住院入院评估数据元素，以确定哪些元素对患者护理至关重要。十二个组织用于达成共识的过程包括确定：（1）真正必要的数据元素；（2）在入院过程中明确需要的哪些数据元素；（3）必须由注册护士（RN）记录的数据元素。
结果是入院患者病史基本临床数据集（APH ECD），使入院文档内容的数量平均减少了 48.5%。早期采用者平均每次入院病史文档记录会话减少了两分钟以上，平均点击次数减少了 30%以上。
创建基本临床数据集是将 EHR 内的护理实践证据与一组预定义的指导原则相结合，以减轻护士文档编制负担的一个例子。为成人入院病史和入院流程建立基本文档组件，通过在患者住院期间的正确时间由正确的人收集正确（必要）的信息，确保有效利用床边护士的时间。确定基本要素还为将组件映射到国家标准提供了一个框架，以促进可共享和可比的护理数据。
