Study finds delays in nurses entering patient data in electronic health records

Significant lag times exist between when nurses assess patient pain scores at the bedside and when those scores are entered into patients' electronic health records, based on a recent study, according to an article that was published in the March issue of General Surgery News. The study's findings were presented at the American Medical Informatics Association's 2014 annual symposium. Researchers from the University of Minnesota analyzed pain scores documented by 6,414 inpatient nurses from January 2013 to January 2014 at 10 hospitals to determine these lag times and their effect on patient care. They also emailed a link to an online survey to 5,876 nurses and observed 25 nurses on inpatient units, according to the study. Of 1,769 responses received, 4% of these nurses reported using just their memory during the lag time rather than writing down the scores. The researchers found the mean lag times ranged from 16 to 33 minutes, with larger hospitals and patients with lower pain scores having longer lag times. The mean delay for patients with severe pain scores was 17 minutes, compared with 48 minutes for no-pain scores, according to the study. "I am not sure how we can study or measure the reliability or accuracy of the documentation in the context of this study, but we will consider that question as we look at impact of delayed documentation in the next phase of this project," lead investigator Tamara Winden, MBA, a graduate research assistant at the University of Minnesota in Minneapolis, said in the article. The investigators said the most common reasons for delaying the score entries included being too busy, having conversations with the patients or their family members, grouping documentation of several patients' pain scores to make better use of their time, and forgetting to enter the data. The nurses suggested ways to reduce the delay, including having lighter workloads, and using EHR alerts for pain reassessment and mobile devices in units that do not have computers in every room, according to the study. "We're interpreting the responses as indicating that the EHR systems aren't as usable as they should be," Winden said in the article. "So we need to redesign our systems or implement other systems that will help expedite pain score documentation by our clinicians."