Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 Apr 28:8:e69651.
doi: 10.2196/69651.

Evaluating Nurses' Perceptions of Documentation in the Electronic Health Record: Multimethod Analysis

Deborah Jacques #  1 , John Will #  1 , Denise Dauterman #  1 , Kathleen Evanovich Zavotsky #  2 , Barbara Delmore #  2 , Glenn Robert Doty #  1 , Kerry O'Brien #  1 , Lisa Groom #  1   3
Affiliations

Evaluating Nurses' Perceptions of Documentation in the Electronic Health Record: Multimethod Analysis

Deborah Jacques et al. JMIR Nurs. .

Abstract

Background: Nurses are one of the largest user groups of the electronic health record (EHR) system, relying on its tools to support patient care and nursing workflows. Recent studies suggested that the redesign of nursing documentation may reduce the time spent in the EHR system and improve nurse satisfaction.

Objective: We aimed to assess nurses' perceptions of the redesigned EHR, evaluate the impact of documentation interventions, and identify future improvement needs.

Methods: Guided by the American Nursing Informatics Association's Six Domains of Burden conceptual framework, this multimethod project combined both qualitative and quantitative approaches. Registered nurses across the academic health system were recruited via email invitations to participate in focus group discussions. The focus groups were conducted via a web conference and ranged from 60 to 90 minutes in duration. The focus group discussions were transcribed and analyzed through thematic analysis. The EHR vendor's time data were used to analyze nurses' time spent in documentation.

Results: In total, 20 registered nurses participated in the focus group discussions, and 17 nurses completed the demographic survey; 88% (15/17) of participants had ≥3 years of EHR experience at the academic health system, and 53% (9/17) self-reported being competent in the EHR system. The following six themes emerged: positive feedback, usability and workflow opportunities, nuisance, training and education, communication, and time spent in the system. EHR vendor time data revealed that the time spent in flowsheets averaged 31.11% per 12-hour shift.

Conclusions: Overall, participants reported a positive experience and that the EHR supported patient care. There are opportunities to further reduce redundancies in documentation and implement programs that support continuous learning about EHR and health technology tools. Specific suggestions include optimizing the oral health assessment tool. Analyzing frontline nursing perspectives in the redesign of EHR workflows is imperative for identifying interventions that support nurses' satisfaction with the EHR.

Keywords: documentation; documentation burden; electronic health record; focus group; nurse; usability.

PubMed Disclaimer

Conflict of interest statement

Conflicts of Interest: None declared.

Figures

Figure 1.
Figure 1.. Improvement of nursing documentation experience: phased implementation and focus groups. EHR: electronic health record.
See this image and copyright information in PMC

Similar articles

See all similar articles

References

    1. Kang MJ, Rossetti SC, Knaplund C, et al. Nursing documentation variation across different medical facilities within an integrated healthcare system. Comput Inform Nurs. 2021 May 3;39(12):845–850. doi: 10.1097/CIN.0000000000000736. doi. Medline. - DOI - PMC - PubMed
    1. Brass CT, Jackson PJ, Lake JE, Spar K, Vincent CH. Congressional Research Service; 2009. [11-04-2025]. American Recovery and Reinvestment Act of 2009 (P.L. 111-5): summary and legislative history.https://crsreports.congress.gov/product/pdf/R/R40537/6 URL. Accessed.
    1. Apathy NC, Holmgren AJ, Adler-Milstein J. A decade post-HITECH: critical access hospitals have electronic health records but struggle to keep up with other advanced functions. J Am Med Inform Assoc. 2021 Aug 13;28(9):1947–1954. doi: 10.1093/jamia/ocab102. doi. Medline. - DOI - PMC - PubMed
    1. Padden J. Documentation burden and cognitive burden: how much is too much information? Comput Inform Nurs. 2019 Feb;37(2):60–61. doi: 10.1097/CIN.0000000000000522. doi. Medline. - DOI - PubMed
    1. 25x5 Documentation Burden Reduction Toolkit. American Medical Informatics Association. [21-06-2024]. https://brand.amia.org/m/3aaa0f687a601441/original/25x5-toolkit.pdf URL. Accessed.

LinkOut - more resources