Relationship between Additional Required Nursing Documentation and Patient Outcomes: A Scoping Review

Rachel Y. Lee; Jennifer Thate; Jennifer Withall; Po-Yin Yen; Kenrick Cato; Sarah C. Rossetti

doi:10.1055/a-2561-3960

Applied Clinical Informatics, Table of Contents

Appl Clin Inform 2025; 16(03): 628-639
DOI: 10.1055/a-2561-3960

Review Article

Relationship between Additional Required Nursing Documentation and Patient Outcomes: A Scoping Review

Authors

Rachel Y. Lee ^*

¹Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, United States
Jennifer Thate^*

¹Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, United States

²Siena College, Loudonville, New York, United States
Jennifer Withall

¹Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, United States
Po-Yin Yen

³Institute for Informatics, Data Science & Biostatistics, Washington University School of Medicine, St. Louis, Missouri, United States
Kenrick Cato

⁴University of Pennsylvania, Philadelphia, Pennsylvania, United States

⁵Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
Sarah C. Rossetti

¹Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, United States

⁶Columbia University Irving Medical Center, School of Nursing, New York, New York, United States

Abstract

Background

Although many aspects of nursing documentation are considered an essential part of clinical communication and care coordination, other types of nursing documentation have been implemented to meet compliance and secondary uses. Adding required documentation without carefully assessing its association with patient outcomes adds excessive documentation burden on nurses. There is a gap in the evidence of the association between additional required nursing documentation and improvements in patient outcomes.

Objectives

This study aimed to synthesize and describe the state of the evidence on the relationship between adding required electronic nursing documentation and improved patient outcomes in inpatient hospital settings.

Methods

Databases were searched using relevant terms for original studies examining the effects of additional required nursing documentation. Two authors screened titles, abstracts, and full texts for eligibility criteria. PubMed, CINAHL (EBSCO), Web of Science, and Embase were searched for data from January 2011 to May 2023.

Results

A total of 47 studies were included. Of the studies reviewed, 57.4% (n = 27) focused only on process measures, primarily measuring documentation compliance, and 42.6% (n = 20) studies included patient outcome measures such as infection rates, length of stay, and falls. Of these studies 45% (n = 9) reported statistically significant relationship between required nursing documentation and improved patient outcomes. Overall quality of evidence was generally low, with 72% (n = 34) being quality improvement studies and only one study being a randomized controlled trial.

Conclusion

The findings of this scoping review suggest an assumed, yet unverified, connection between added required nursing documentation and improved patient outcomes that is not substantiated by high-quality empirical evidence. The paucity of studies with significant findings—and the methodological weaknesses of those that report them—suggest the need for critical examination of documentation practices that are truly beneficial to patient outcomes versus those documentation practices that are excessively burdensome.

Keywords

nursing documentation - documentation burden - nursing informatics - inpatient care - electronic health records

Full Text

References

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