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新冠疫情期间电子健康记录文档记录频率的变化

EHR Documentation Frequency Changes Across the COVID-19 Pandemic.

作者信息

Fan Hao, Rossetti Sarah, Mugoya Rosemary, Jia Haomiao, Thate Jennifer, Finnegan Amy, Lai Albert M, Cato Kenrick, Yen Po-Yin

机构信息

Institute for Informatics and Data Science, Washington University School of Medicine, St. Louis, MO.

Department of Biomedical Informatics, Columbia University Medical Center, New York, NY.

出版信息

AMIA Annu Symp Proc. 2025 May 22;2024:388-397. eCollection 2024.

Abstract

Documentation is crucial for patient care. However, the increased documentation burden raises questions about its clinical value. The COVID-19 pandemic provided an opportunity to explore nurses' documentation patterns due to increased patient care demands and the implementation of documentation relaxation policy. We conducted a trend analysis to examine documentation frequency over time, including phases during the pandemic and the implementation of the Surge Documentation, a documentation relaxation policy at a Midwest academic medical center. We analyzed the trend changes using segmented regression and mixed-effect Poisson regression. We found that documentation frequency increased in response to the pandemic due to the heightened demand for patient care and significantly decreased with the implementation of Surge documentation. The reduction was particularly noticeable in flowsheets unrelated to patient acuity. The study highlighted nurses' critical thinking in prioritizing documentation based on patient care. Future policies should support nurses'autonomy in documentation without imposing excessive requirements.

摘要

记录对于患者护理至关重要。然而,记录负担的增加引发了对其临床价值的质疑。由于患者护理需求增加以及实施了记录放宽政策,新冠疫情为探索护士的记录模式提供了契机。我们进行了一项趋势分析,以检查随时间推移的记录频率,包括疫情期间的各阶段以及中西部一家学术医疗中心实施的激增记录(一种记录放宽政策)。我们使用分段回归和混合效应泊松回归分析了趋势变化。我们发现,由于对患者护理的需求增加,记录频率在疫情期间有所上升,而随着激增记录的实施,记录频率显著下降。这种下降在与患者病情严重程度无关的流程图中尤为明显。该研究突出了护士在根据患者护理情况优先进行记录方面的批判性思维。未来的政策应支持护士在记录方面的自主权,而不施加过多要求。

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