Abstract:

Objective To conduct a scoping review of studies on nursing documentation burden in the context of electronic health record（EHR） system application. Methods Following the methodological framework of scoping reviews，computerized searches were performed in CNKI，Wanfang Database，SinoMed，PubMed，Web of Science，EBSCO，OVID，and Cochrane Library. The search period spanned from database inception to June 20，2025. Two researchers independently conducted literature screening，inclusion，and analysis. Results A total of 30 studies were included. The findings indicated that nursing documentation in the context of EHR system application could be classified into five categories：structured nursing records，documentation supporting physician order execution，documentation related to hand-offs and inter-professional communication，documentation for quality management and regulatory requirements，and EHR system operation and information maintenance tasks. Assessment tools comprised two categories：subjective assessment tools（e.g.，National Aeronautics and Space Administration Task Load Index，Burden of Documentation for Nurses and Midwives） and objective assessment tools（e.g.，time-motion studies，work log analysis，timestamp data analysis）. Influencing factors encompassed multiple dimensions：technological，task-related，organizational，policy-related，and individual. Intervention methods focused on technological optimization，workflow redesign，and organizational change. Conclusion The burden of nursing documentation in the context of EHR system application is prevalent and significant. Future efforts should further strengthen systematic research on nursing documentation burden，in order to build an efficient and humanistic working environment for nurses，and promote the sustainable development of the nursing profession.

Key words: Nurses, Electronic Health Records, Documentation Burden, Scoping Review