DNP865 Module 3 assignment: documentation workflow map and critique, a full sample

Forty-Six Minutes and Eleven Screens: Mapping, Then Critiquing, the Nursing Admission History in an Electronic Health Record

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP865: Healthcare Technologies and Informatics

Instructor Name

Month Day, Year

Forty-Six Minutes and Eleven Screens: Mapping, Then Critiquing, the Nursing Admission History in an Electronic Health Record

Complaints about electronic documentation are common, but they are more persuasive when based on a careful description of the actual work. This paper maps, step by step, how nurses complete the admission history on a composite 32-bed adult medical and surgical unit, using observation and electronic audit data, and only then critiques it using a usability framework and evidence on documentation burden. It ends with specific redesign recommendations.

Method

The DNP student observed 12 admission histories across day and evening shifts, recording each screen, field, and interruption, and reviewed electronic audit logs for 200 admissions over one month, which record time spent in each documentation section. Nurses were asked after each observed admission which fields they found useful. No patient identifiers were recorded.

The Workflow, Step by Step

The admission history begins after the patient arrives and initial vital signs are taken. The median total time in the admission navigator was 46 minutes, spread across 11 screens completed in a fixed order.

Screen 1, reason for admission and source, is typed as free text, even though the emergency department note already contains it. Screen 2, allergies, repeats questions the emergency department nurse asked, with no display of the allergies already entered. Screen 3, home medications, takes the longest single block, a median of 11 minutes, because nurses list medications that pharmacy technicians reconcile again later. Screen 4, past medical and surgical history, duplicates the physician's history. Screens 5 through 7 contain risk assessments: falls, pressure injury, nutrition, suicide risk, and functional status, each on a separate form with its own scoring. Screen 8, psychosocial and spiritual history, includes 14 questions. Screen 9, advance directives, asks whether a directive exists but does not link to the document if one is on file. Screen 10, learning needs and preferences, and screen 11, discharge planning, close the navigator.

Nurses were interrupted a median of four times per admission, most often by call lights and by the need to administer first-dose medications. Observed nurses left the navigator partly complete in 7 of 12 admissions and came back to it later, in several cases only as the shift was ending.

Where the Time Goes

Audit data showed that 38 percent of the admission time was spent entering information that already existed elsewhere in the record: the reason for admission, allergies, medical history, and home medications. Another 17 percent went to psychosocial questions, of which nurses rated only four as useful for their care. Only the risk assessments were consistently described as valuable, because they trigger specific interventions. Nearly half the admission history asked nurses to record what the record already knew, while the parts that changed care were scattered across three screens.

This pattern reflects a wider problem. In a time and motion study of 767 medical-surgical nurses in 36 hospitals, documentation accounted for 35.3 percent of nursing practice time, more than any other category, while patient assessment and reading vital signs accounted for 7.2 percent (Hendrich et al., 2008). Research on the problem also lacks a common yardstick: a scoping review found that studies of physicians and nurses measure burden through time in the record, amount documented, or users' own ratings, so results rarely line up across settings (Moy et al., 2021); the audit and observation data used here provide a local measure that can be repeated after redesign.

A Usability Critique

Zhang and Walji (2011) proposed the TURF framework, which defines usability as how useful, usable, and satisfying a system is for users to accomplish work, and which distinguishes the work domain, what must be done, from the representation, how the system presents it. Viewed through TURF, the admission history fails on usefulness, since much of it does not support the nurse's work, and on usability, since it forces a fixed order that ignores interruptions and hides existing information. The representation mismatches the work: nurses need to see what is already known and fill gaps, but the system presents empty forms as if the patient were new to the organization. Satisfaction was low, with nurses describing the navigator as "charting for someone else."

Why the Design Persists

Understanding why the admission history looks this way helps explain why redesign is difficult. Many of its questions were added one at a time in response to regulatory surveys, accreditation findings, or single events, each by a different committee, and none was ever removed. Several psychosocial questions were added to meet a reporting requirement that has since changed. The fixed screen order reflects how the vendor's template was built at go-live a decade ago, not how nurses work today. No one owns the admission history as a whole; each form has a separate owner. Redesign therefore requires a governance decision as much as a technical one: a single documentation committee, led by nursing informatics with frontline nurses as members, with authority to remove fields and a rule that any new field must replace an old one or show how it will change care.

Redesign Recommendations

First, prefill fields with existing data, including the reason for admission, allergies, medical history, and home medications from the emergency department and prior encounters, and ask nurses to verify and add rather than retype. Second, remove or relocate low-value psychosocial questions, keeping those nurses identified as useful and moving others to social work. Third, consolidate the risk assessments onto one screen that shows scores together and links each to its intervention order set. Fourth, allow screens to be completed in any order and saved at any point, with a clear display of what remains. Fifth, link the advance directive field to the document when one is on file. The expected result is a shorter, more useful admission history; the audit and observation methods used here will be repeated after changes to measure time saved and nurse satisfaction.

Conclusion

Mapping the nursing admission history screen by screen before criticizing it revealed a specific pattern: nearly half the time was spent re-entering information the record already held, while the valuable risk assessments were fragmented. A usability framework explains why the design frustrates nurses, and targeted redesign offers a way to return time to patient care.

References

Hendrich, A., Chow, M. P., Skierczynski, B. A., & Lu, Z. (2008). A 36-hospital time and motion study: How do medical-surgical nurses spend their time? The Permanente Journal, 12(3), 25-34. https://doi.org/10.7812/TPP/08-021

Moy, A. J., Schwartz, J. M., Chen, R., Sadri, S., Lucas, E., Cato, K. D., & Rossetti, S. C. (2021). Measurement of clinical documentation burden among physicians and nurses using electronic health records: A scoping review. Journal of the American Medical Informatics Association, 28(5), 998-1008. https://doi.org/10.1093/jamia/ocaa325

Zhang, J., & Walji, M. F. (2011). TURF: Toward a unified framework of EHR usability. Journal of Biomedical Informatics, 44(6), 1056-1067. https://doi.org/10.1016/j.jbi.2011.08.005