Halley Ruppel, Amina Khan, Rose Mintor, Jessica Nguyen, Meghan McNamara, Brooke Luo, Michelle Kelly, Kenrick Cato, Elizabeth B Froh
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引用次数: 0
Abstract
This modified explanatory sequential mixed methods study sought to inform redesign of nursing notes in the electronic health record. In the context of OpenNotes and patient and family access to nursing notes via the inpatient portal, redesigning nursing notes offers an opportunity to enhance family-centered care delivery and reduce nurses' documentation burden. We analyzed data on note views via the inpatient portal for 258,841 nursing notes; annotated the contents of 100 nursing notes; and conducted interviews with 18 families and 8 nurses. Our findings support recommendations for more specific care plans, eliminating redundancies, and emphasizing nursing care and expertise otherwise absent from the patient chart. The results of this descriptive study lay the groundwork for pilot testing new nursing note structures.
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