Completion of electronic nursing documentation of inpatient admission assessment: insights from Australian metropolitan hospitals

Abstract

AbstractIntroductionElectronic nursing documentation is an essential aspect of inpatient care and multidisciplinary communication. Analysing data in electronic medical record (eMR) systems can assist in understanding clinical workflows, improving care quality, and promoting efficiency in the healthcare system. This study aims to assess timeliness of completion of an electronic nursing admission assessment form and identify patient and facility factors associated with form completion in three metropolitan hospitals.Materials and MethodsRecords of 37,512 adult inpatient admissions (November 2018-November 2019) were extracted from the hospitals’ eMR system. A dichotomous variable descriptive of completion of the nursing assessment form (Yes/No) was created. Timeliness of form completion was calculated as the interval between date and time of admission and form completion. Univariate and multivariate multilevel logistic regression were used to identify factors associated with form completion.ResultsAn admission assessment form was completed for 78.4% (n=29,421) of inpatient admissions. Of those, 78% (n=22,953) were completed within the first 24 hours of admission, 13.3% (n=3,910) between 24-72 hours from admission, and 8.7% (n=2558) beyond 72 hours from admission. Patient length of hospital stay, admission time, and admitting unit’s nursing hours per patient day were associated with form completion. Patient gender, age, and admitting unit type were not associated with form completion.DiscussionForm completion rate was high, though more emphasis needs to be placed on the importance of timely completion to allow for adequate patient care planning. Staff education, qualitative understanding of delayed form completion, and streamlined guidelines on nursing admission and eMR use are recommended.Statement on conflicts of interestDeclarations of interest: noneSummary TableWhat was already known on the topicElectronic clinical documentation is an essential aspect of inpatient care and multidisciplinary communicationTimely completion of documentation enables prompt team communication and facilitates quality patient care planningAustralian hospitals are moving towards fully adopting eMR-based technologies to manage patient care processes and multidisciplinary communicationWhat this study added to our knowledgeThe timeliness of electronic nursing documentation can be improvedThere are patient- and facility-related factors which influence the completion of electronic nursing formsThe application of advanced modelling techniques to existing eMR data assists in understanding clinician practices, processes and workflows