Documentation in nursing is important to keep care continuous, follow laws, and help communication among healthcare workers. But many nurses find documentation takes a lot of time and is often done in small, broken-up steps. This happens mostly because of how electronic health record (EHR) systems are designed. These systems often make nurses click through many screens, enter the same data again and again, and use complicated forms that need lots of clicking and scrolling. Having to do tasks that do not add value, like entering the same information multiple times and dealing with unclear interfaces, causes frustration, lowers productivity, and leads to burnout in nurses.
Studies show that nurses spend a large part of their work shifts inside EHR systems. This means they have less time to care for patients directly, which is their main job. Reducing how much clicking and scrolling nurses must do to finish documentation can help improve their workflow and job satisfaction.
Duke University Health System started a project to improve the way their EHR’s patient assessment templates and forms worked. The aim was to make performance better, avoid repeating work, and remove tasks that did not add value. This made the nursing documentation process simpler. The project used proven best practices focused on ease of use and function. It also made sure documentation matched real clinical work more closely.
Changes made included removing the assessment type row, adding reassessment sections to the top parts of flowsheets, and switching to dropdown menus for noting body system changes instead of doing full assessments repeatedly. These changes greatly cut down the steps needed. Nurses could document reassessments with fewer clicks and simpler navigation.
The results showed:
Video motion-time recording and the Keystroke Level Model helped measure these cuts accurately. They showed that the redesign removed many unnecessary clicks and scrolling steps that earlier made documentation harder.
The changes had a real effect on nursing staff. By making documentation easier, the redesign reduced the repetitive and frustrating tasks that added to nurse workload. Nurses could use the time saved to focus more on activities that help patients, improving care.
Mary R. Lindsay and Kay Lytle from Duke University Health System said these improvements helped nurses work better and feel happier in their jobs. Lowering the documentation burden also cut down on fatigue and frustration caused by EHR use. The time saved added up to several hours in a 12-hour shift, allowing nurses to spend more time with patients for assessment and care planning.
Reducing documentation time also improves care quality and safety. When nurses spend less time on complex EHR navigation and more time with patients, they can spot problems sooner, take action quickly, and communicate better with other care teams.
Hospitals in the U.S. still face challenges with technology and daily clinical workflows. Even though EHRs are required for federal payment and have made patient information easier to access, difficult-to-use systems hurt nursing efficiency and satisfaction. EHRs often have complex interfaces and many documentation demands coming from rules and billing needs.
Hospital leaders, owners, and IT managers in the U.S. are becoming more aware of how “click and scroll burden” negatively affects clinicians. Patients also feel the effect when nurses have less time available for them. Hospitals need to go beyond just meeting rules and build systems that truly support nursing work in real settings.
Hospitals can learn from the Duke project and try similar workflow changes themselves. Using data that shows how much time tasks take and getting feedback from nurses who work daily with the EHR is very important. Across the country, using data from vendors like EPIC and testing how people use the system can help find problem areas and improve EHR design.
New AI and automation tools offer helpful ways to reduce documentation workload. Artificial intelligence can help healthcare workers by automating repeated tasks like answering patient questions, scheduling, and entering documentation. Some companies, like Simbo AI, provide phone automation and answering services powered by AI. These services help cut down administrative work in clinics and hospitals.
By adding AI automation, hospitals can lower the time nurses spend on non-clinical jobs. For nursing documentation, AI tools such as voice recognition and natural language processing can turn spoken notes into organized EHR entries. This cuts down clicks and typing while keeping documentation detailed and following rules.
AI can also study how data is entered and suggest workflow improvements made for nursing routines. Automated reminders for reassessments and alerts help nurses prioritize documentation without needing to navigate complex forms manually. This makes clinical work smoother and lets nurses give proper care on time.
For hospital IT and management, investing in AI makes sense for efficiency and staff well-being. By freeing nurses from repetitive documentation and improving communication, these tools can help lower burnout and reduce nurse turnover.
Hospital managers who want to improve nursing satisfaction and workflow by cutting down clicks and scrolling in EHRs can follow these steps:
Hospitals in the U.S. face growing demands for efficiency, quality, and keeping their workforce healthy. Lowering documentation burdens by redesigning workflow and using AI technology is important to improve nursing satisfaction, clinical workflow, and patient care.
Reducing click and scroll workloads in EHR documentation saves nurses time, cuts their workload, and allows more patient care. These changes, together with AI tools, can help healthcare facilities in the United States meet clinical and operational goals in a complex healthcare system.
The primary objective was to improve performance, reduce duplication, and remove nonvalue-added tasks by redesigning the patient assessment template in the EHR using best practice approaches.
A quality improvement approach and a pre-/post-design were utilized to implement and evaluate best practices for redesigning standardized flowsheet documentation workflows.
The redesign resulted in an 18.5% decrease in documentation time, a reduction of 7 to 12% in total time spent on flowsheets, and significant decreases in steps needed for reassessment documentation.
Revising documentation practices led to decreased workload, improved quality of care, and enhanced staff satisfaction by reducing redundant tasks and click burden.
The saved time allowed nurses to reallocate hours to value-added patient care activities during shifts.
The assessment type row was removed, a reassessment section was added to the flowsheets, and documentation practices were revised to streamline the entry based on initial assessments.
Click and scroll burdens, defined as steps in documentation, were analyzed using video motion-time recording and the Keystroke Level Model to capture the time and effort involved.
The redesign resulted in a decrease of 88% to 97% in the number of steps required to complete reassessment documentation.
The study highlights the need for improved usability and functionality in EHRs to facilitate better clinical workflows and reduce documentation burdens for healthcare providers.
The workflow redesign significantly improved productivity by decreasing documentation time and redundancy, ultimately enhancing the quality of patient care and staff satisfaction.
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