Author Affiliations: Dignity Health Phoenix System Office (Mr McIlreevy, Ms Rylee, and Ms Shields-Tettamanti), Phoenix, Arizona; Intermountain Healthcare (Dr Gee), Salt Lake City, Utah; and College of Nursing, University of Utah (Dr Gee), Salt Lake City.
Comput Inform Nurs. 2021 May 1;39(5):248-256. doi: 10.1097/CIN.0000000000000695.
Moving toward the electronic health record increases the quality of information gathered. However, nurses argue that the electronic health record is an added burden. The aim of this study was to evaluate the removal of duplicative or unnecessary fields and reordering fields on the admission form to increase documentation that is meaningful to the patient story. A team of approximately 60 interdisciplinary clinicians engaged in document review to evaluate the importance of each field and removal or modification based on those findings. After a review of the 251 fields, the authors reduced the form to 124 fields, and the percentage of unfields by 31%. After outlier removal, the average time to complete the admission form decreased by 2.88 minutes. The new form showed a reduction of 36.71% of the use of the free text advance directive. Additionally, nurses' perceptions of the form significantly improved from pretest to posttest in terms of satisfaction with the form, time to complete, usability and usefulness, question flow, and length of the form. This study shows that an interdisciplinary team can effectively work together to optimize the Adult Admission History Form, increasing the quality of documentation while reducing the time to complete.
向电子健康记录迈进可以提高所收集信息的质量。然而，护士们认为电子健康记录是一种额外的负担。本研究的目的是评估删除重复或不必要的字段并重新排列入院表中的字段，以增加对患者病历有意义的文档。一组大约 60 名跨学科临床医生参与了文件审查，以评估每个字段的重要性，并根据这些发现进行删除或修改。在审查了 251 个字段后，作者将表单减少到 124 个字段，未填字段的百分比减少了 31%。去除异常值后，填写入院表单的平均时间减少了 2.88 分钟。新表单在使用自由文本预先指示的情况下减少了 36.71%。此外，护士对表单的看法在满意度、完成时间、可用性和有用性、问题流程以及表单长度方面都有了显著提高。本研究表明，一个跨学科团队可以有效地合作，优化成人入院病史表，在缩短完成时间的同时提高文档的质量。
