Nursing Documentation Time During Implementation of an Electronic Medical Record

Objective To determine, within the context of all nursing duties, the amount of time nurses spend on documentation during the implementation of an electronic medical record (EMR) on an intrapartum unit. Background Increased documentation needs during EMR implementation may necessitate increased staffing requirements in an already labor-intensive and demanding environment. Methods A work-sampling study was conducted over a 14-day study period, and 18 of 84 (21%) potential 4-hour observation periods were selected. During each period, a single observer made 120 observations and, on locating a specific nurse, immediately recorded that nurse’s activity on a standardized and validated instrument. Categories of nursing activities included documentation, bedside care, bedside supportive care, nonbedside care, and nonpatient care. Results A total of 2160 observations were made. The total percentage of nursing time spent for documentation was 15.8%, 10.6% on paper and 5.2% on the computer. The percentage of time spent on documentation was independently associated with day versus night shifts (19.2% vs 12.4%, respectively). Conclusions Despite charting concurrently on both paper and computer, the amount of time spent on documentation was not excessive, and was consistent with previous studies in which neither electronic nor “double charting” occurred.