FEATURESNursing Documentation Variation Across Different Medical Facilities Within an Integrated Healthcare SystemKang, Min-Jeoung RN, PhD; Rossetti, Sarah Collins RN, PhD; Knaplund, Christopher MPhil; Chang, Frank Y. MSE; Schnock, Kumiko O. RN, PhD; Whalen, Kimberly RN, MS; Gesner, Emily J. DNP, RN-BC; Garcia, Jose P. BA; Cato, Kenrick D. RN, PhD; Dykes, Patricia C. RN, PhD Author Information Author Affiliations: College of Nursing, The Catholic University of Korea, Seoul, Republic of Korea (Dr Kang); Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Boston, MA (Mr Chang, Dr Schnock, Mr Garcia, and Dr Dykes); Harvard Medical School, Boston, MA (Dr Schnock, and Dr Dykes); School of Nursing (Dr Rossetti, Mr Knaplund, and Dr Cato) and Department of Biomedical Informatics (Dr Rossetti), Columbia University, New York, NY; Massachusetts General Hospital, Boston, MA (Ms Whalen); University of Massachusetts-Dartmouth, College of Nursing and Health Sciences, Department of Community Nursing, North Dartmouth, MA (Dr Gesner). This study was supported by NINR 1R01NR016941-01: Communicating Narrative Concerns Entered by RNs (CONCERN). The study was approved by the Mass General Brigham institutional review board. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Min-Jeoung Kang, RN, PhD, College of Nursing, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea ([email protected]). CIN: Computers, Informatics, Nursing: December 2021 - Volume 39 - Issue 12 - p 845-850 doi: 10.1097/CIN.0000000000000736 Buy Metrics Abstract The purpose of this study was to demonstrate nursing documentation variation based on electronic health record design and its relationship with different levels of care by reviewing how various flowsheet measures, within the same electronic health record across an integrated healthcare system, are documented in different types of medical facilities. Flowsheet data with information on patients who were admitted to academic medical centers, community hospitals, and rehabilitation centers were used to calculate the frequency of flowsheet entries documented. We then compared the distinct flowsheet measures documented in five flowsheet templates across the different facilities. We observed that each type of healthcare facility appeared to have distinct clinical care foci and flowsheet measures documented differed within the same template based on facility type. Designing flowsheets tailored to study settings can meet the needs of end users and increase documentation efficiency by reducing time spent on unrelated flowsheet measures. Furthermore, this process can save nurses time for direct patient care. Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.