Electronic Health Record Strategies for Improving Nurse Documentation in the Hospital Setting

Electronic health record support nurses’ work in many ways; however, nursing documentation within the system has also been associated with burden and noncompliance with organizational and regulatory requirements. An increasing number of studies have analyzed nursing documentation burden and noncompliance, but no scoping review has been conducted that focuses on electronic health record–based strategies for improving nursing documentation. This scoping review aimed to identify electronic health record–based strategies for improving nursing documentation in hospital settings. The Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews guidelines were used, and databases MEDLINE, Web of Science, and CINAHL were searched on April 1, 2024. A total of 652 studies were retrieved, of which 25 were included at the full-text level. Six documentation issues emerged across the studies, with 44% identifying documentation compliance as the main issue. Three electronic health record–based strategies, such as organizational change, end-user reminder system, and financial incentives, regulation, and policy, were identified. Six documentation improvement outcomes with findings were identified, with 52% of the studies’ outcome demonstrating improved documentation compliance. This review identified electronic health record–based and supplemental strategies that concentrate on improving nursing documentation. More research is needed to identify how these strategies may affect other measures, such as patient care outcomes, accuracy and quality of nursing documentation, and costs associated with nursing time spent on documentation activities.