Publication date: May 26, 2025

Documentation is crucial for patient care. However, the increased documentation burden raises questions about its clinical value. The COVID-19 pandemic provided an opportunity to explore nurses’ documentation patterns due to increased patient care demands and the implementation of documentation relaxation policy. We conducted a trend analysis to examine documentation frequency over time, including phases during the pandemic and the implementation of the Surge Documentation, a documentation relaxation policy at a Midwest academic medical center. We analyzed the trend changes using segmented regression and mixed-effect Poisson regression. We found that documentation frequency increased in response to the pandemic due to the heightened demand for patient care and significantly decreased with the implementation of Surge documentation. The reduction was particularly noticeable in flowsheets unrelated to patient acuity. The study highlighted nurses’ critical thinking in prioritizing documentation based on patient care. Future policies should support nurses’autonomy in documentation without imposing excessive requirements.

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Semantics

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