The Role of Nursing Informatics in Enhancing Clinical Documentation Accuracy and Patient Safety

Posted: May 13, 2021

• Kara Walsh
• Elias Daniels
• Rowan Hunter

Abstract

Clinical documentation represents a critical component of healthcare delivery, serving as the primary mechanism for communication among healthcare providers, supporting clinical decision-making, and ensuring continuity of care. The accuracy and completeness of nursing documentation directly influence patient safety outcomes, yet traditional documentation methods often introduce significant challenges including time burden, cognitive load, and potential for error. Nursing informatics, defined as the integration of nursing science with information and analytical sciences, offers promising solutions to these persistent challenges. This research addresses a significant gap in the literature by examining how specialized nursing informatics interventions, specifically designed around nursing workflow and cognitive processes, can simultaneously enhance documentation accuracy and patient safety. The transformation from paper-based to electronic health records has yielded mixed results in nursing practice. While EHRs have improved accessibility of patient information, they have often introduced new challenges including documentation burden, alert fatigue, and workflow disruption. Previous research has predominantly focused on physician-oriented informatics solutions or generic EHR implementations without adequate consideration of nursing-specific documentation requirements and workflow patterns. This study introduces a novel approach that centers nursing practice as the foundational element for informatics design, recognizing that nursing documentation serves distinct purposes including care coordination, legal documentation, and communication of nursing clinical judgment. Our research addresses three primary questions: How do nursing-specific informatics interventions impact documentation accuracy compared to conventional EHR systems? What is the relationship between improved documentation accuracy and specific patient safety indicators? How do nursing informatics solutions