绘制前进之路：关于文件和变化的护理观点

IF 3.7 2区医学 Q1 NURSING

Nursing Outlook Pub Date : 2025-06-27 DOI:10.1016/j.outlook.2025.102463

Lisa G. Johnson MSN, RN, Tamara G.R. Macieira PhD, RN, Olatunde O. Madandola MPH, RN, Karen J.B. Priola MSCIS, Gail M. Keenan PhD, RN, FAAN

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引用次数: 0

摘要

立法和研究没有充分考虑到护士面临的独特的电子健康记录（EHR）文件负担。目的通过确定医院护士认为最关键的电子病历变化，探索文档负担，作为提高护士电子病历可用性和功能的基础步骤。方法在2024年6月至7月期间，通过电子邮件和短信向美国五个州随机选择的38,000名注册护士（RNs）进行了一项电子调查，并进行了预先测试；146名住院患者提供了反映国家注册护士统计数据的人口统计数据和开放式反馈。讨论对这项快速、具有成本效益的调查的无限制答复产生了四个主题。最常提到的优先事项是改进人机交互，特别是用户界面功能（56%）和减少冗余文档（17%）。这些见解可以支持以护士为中心的设计和人工智能增强策略，以简化文档。结论护士的建议为开发电子病历系统提供了基础，减少了过多的文件负担，提高了护理的质量、准确性和有效性。

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Charting the path forward: Nursing perspectives on documentation and change

Background

Legislation and research have not sufficiently considered the unique electronic health record (EHR) documentation burdens faced by nurses.

Purpose

Explore documentation burden by identifying the EHR changes hospital-based nurses find most critical, serving as a foundational step in enhancing EHR usability and functionality for nurses.

Methods

An electronic survey, developed and pre-tested, was emailed and texted to 38,000 randomly selected registered nurses (RNs) across five U.S. states (June–July 2024); 146 inpatient respondents provided demographics mirroring national RN statistics and open-ended feedback.

Discussion

Four themes emerged from open-ended responses to this rapid, cost-effective survey. The most frequently cited priority was improving human-computer interaction, particularly user interface features (56%) and reducing redundant documentation (17%). These insights can support nurse-centered design and AI-enhanced strategies to streamline documentation.

Conclusion

Nurses’ recommendations provide a foundation for developing EHR systems that reduce excessive documentation burden while improving quality, accuracy, and effectiveness of nursing care.

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来源期刊

Nursing Outlook 医学-护理

CiteScore

6.20

自引率

7.00%

发文量

109

审稿时长

25 days

期刊介绍： Nursing Outlook, a bimonthly journal, provides innovative ideas for nursing leaders through peer-reviewed articles and timely reports. Each issue examines current issues and trends in nursing practice, education, and research, offering progressive solutions to the challenges facing the profession. Nursing Outlook is the official journal of the American Academy of Nursing and the Council for the Advancement of Nursing Science and supports their mission to serve the public and the nursing profession by advancing health policy and practice through the generation, synthesis, and dissemination of nursing knowledge. The journal is included in MEDLINE, CINAHL and the Journal Citation Reports published by Clarivate Analytics.