Direct nursing care includes activities that a nurse performs to assist the treatment and well-being of patients and to meet their health demands, whereas indirect nursing care includes activities such as management, documentation, and communication, which support nursing care [1]. Nursing records refers to the recording of patients’ status, the care or service provided to them, patient information collected through the nursing process, and a combination of nursing activities and professional care [2]. Nursing records are mandated and have a nonlinear, two-way feedback loop for the nursing process—assessment, diagnosis, planning, implementation, and evaluation. Similar to professional records, nursing records follow six principles (i.e., factuality, accuracy, completeness, timeliness, organization, and compliance with standards) [3].

With rapid advances in information technology, healthcare providers actively strive to implement hospital information systems, which are computerized systems that collect, process, and effectively manage the information needed for practice, research, education, and management [4]. Nursing information systems manage nursing services and resources within the hospital information system, and manage nursing tasks in which data are collected, transformed, stored, extracted, displayed, and communicated [5]. The nursing information system, as a part of an Electronic Medical Record (EMR) system, manages the standardized nursing data to perform tasks, effectively use nursing personnel, improve documentation and communication, track nursing services and outcomes, and calculate nursing fees. All these tasks are ultimately linked to improving the quality of patient care [6].

Regarding nursing documentation that is maintained on nursing information systems, one previous study found that nurses working in a university hospital stayed logged-in to the nursing information system for an average of at least 10 hours per day and generated nursing documentation of at least one line per minute in various nursing modules in the nursing information system. Specifically, tasks related to nursing diagnosis and nursing activity in a structured format were most frequently entered, with an average of 240 lines per day for each nurse [7]. In a study that analyzed nurses’ tasks, it was reported that, among indirect nursing activities, nurses spent most of their time on ‘nursing records and review’ [8]. These studies demonstrated that electronic nursing documentation is one of the essential nursing activities, and that it takes up significant nursing time.

Nurses and other health care providers aim to share information about patients and organizational functions that are accurate, timely, contemporaneous, concise, thorough, organized, and confidential [2]. Many heath care providers regard information included in records as important, but the actual recording process is often overlooked [9]. Amidst nurses’ busy schedules and the urgent demands that arise during shifts, they tend to think that documenting is sometimes a disruption of direct patient care, which leads them to engage in documentation after their shift is completed [10]. One study reported that nurses tended to get off work later than the designated time in all shifts owing to nursing documentation, which occurred 11.7% of the times on the day shift, 10.8% on the evening shift, and 6.1% on the night shift [11].

Since the implementation of electronic nursing documentation systems, studies have examined the use of standard terminologies in electronic nursing documentation [1213], and a comparative analyses of nursing records before and after the implementation of an electronic nursing documentation system was conducted [1415]. However, although a task analysis revealed that the time spent on indirect nursing care, such as documentation time, had decreased due to the use of hospital information systems [8], there were no attempts to examine the timeliness of electronic nursing documentation using the times entered in the hospital information systems. Therefore, the purpose of this study was to investigate the factors associated with the timeliness of electronic nursing documentation using entry times in the EMR system. These factors were then divided into nurse-associated and patient-associated factors.

In this study, we examined factors associated with the timeliness of electronic nursing documentation using the entry time of electronic nursing documentation by nurses. Although hospital information systems and EMR systems have been implemented for a long time, to our knowledge, no study had yet analyzed the nurses’ documenting patterns.

Nursing documentation is used as an effective communication method among healthcare professionals. However, nurses often consider the documentation of these records as a burden or a task that interrupts patient care. Sufficient time and resources that can support documentation are required to produce high-quality nursing documentation [2]. Nursing activities, such as nursing problems, daily plans and goals, admission assessment, routine assessment, nursing intervention, and evaluation, appear in the system. These are diverse and recursive processes; however, the nursing information systems were often developed without sufficiently reflecting the user experience, which resulted in multiple screens, and redundant data entry required on different screens [19]. This indicates that the EMR systems’ accessibility decreases and it takes a new user a longer time to become accustomed to the system.

We observed that there was a statistically significant difference in timeliness between nurses with one year or less nursing experience and those with more years of experience, with 68.5% and more than 80% of timely documentation within the working hours, respectively. Based on the odds ratio, nurses from all other groups completed documentation within their work hours, with more experienced nurses showing timeliness two times more often than did those with 1 year or less experience. Thus, it seems that advanced beginner nurses have difficulty in getting used to the nursing information system. A study on the experience of a novice nurse in becoming an advanced beginner nurse [20] found that novice nurses experienced a sense of inadequacy because they were not accustomed to the overall workflow, systems and administrative procedures. Although this group of nurses received nursing documentation entry training during their orientation period, it is evident that they need more time to become proficient in their tasks, including nursing documentation. This shows that support is needed in order for new nurses to get familiar with their various tasks and the overall workflow. A study reported that providing a manual to encourage nurses to self-learn at their own pace resulted in increased task proficiency [21]. This indicates that various approaches are necessary until new nurses are fully accustomed to their work and environment.

Nursing shifts were a significant factor associated with timeliness, where the incidence of timely nursing documentation was 9.19 times higher in the night shift as compared to that in the day shift. Similarly, weekends also showed higher timely nursing documentation entry incidence than did weekdays. For nurses working on night shifts or weekends, fewer unpredictable incidents may have led to the higher timeliness as compared to day/evening shifts or weekdays, when there is usually more work to do, e.g., admissions and discharges, surgeries, procedures, and tests.

However, difficulties in the timeliness of electronic nursing documentation cannot be simply attributed to the volume of records alone. Upon examining the differences between departments, it was found that there were 1,023 and 1,108 fewer internal medicine department patients as compared to surgery department patients, with a record volume of 551,595 and 796,116, respectively. Yet the timeliness of nursing documentation for surgery patients was 1.08 times higher than was that for internal medicine patients. A previous study that examined the activity log data of nursing information systems [19] found that there were several repetitive nursing tasks. Such nursing tasks do not occur independently; rather, they influence one another so that nursing tasks can be carried out effectively when nurses predict which tasks will affect others. In that sense, most surgery patients have surgical treatments that are pre-planned; therefore, their nursing tasks are more predictable than are those of internal medicine patients. On the other hand, it is more difficult to predict tasks for internal medicine patients because the treatments and patient status tend to change unexpectedly.

This study had limitations in that the analysis was performed using only some wards in one hospital; thus, the findings may not be generalizable. We were unable to find differences according to the EMR systems in multiple domestic institutions that were developed with various designs and functions. Thus, further studies are needed to include data from other medical institutions to examine nurses’ recording patterns. Because we only analyzed records for adult patients in general wards, there is a need for a study using various clinical environments and patient populations as subjects, such as intensive care units and emergency rooms.

We found that nursing documents were typically completed outside of work hours when a nurse had little experience, worked during the day shift or weekdays, and when tasks were unpredictable. To implement a system that increases the timeliness of electronic nursing documentation, we must assess the characteristics of nursing tasks and analyze the nursing workflow in detail. Because no previous studies have used the entry time as was done in the present study, we will be able to assess the entry form of nursing documentation in more detail through a replication study in various environments. We also believe this will contribute to the creation of more convenient and effective entry forms in hospital information systems while maintaining the quality of nursing documentation.