Dr. Brita's Blog

The Overwhelming Burden of Nursing Documentation - Part 1

Posted by Dr. Brita Hansen on Jul 18, 2019 4:11:53 PM
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Jul. 18, 2019 - The burden of documentation is a well-known challenge in healthcare. Now, we have a clearer understanding of the problem, thanks to a recent study shared at the American Medical Informatics Association Annual Symposium and published in December 2018 by the National Center for Biotechnology Information.

The study, “Quantifying and Visualizing Nursing Flowsheet Documentation Burden in Acute and Critical Care,” includes some startling data points:

  • 19 to 35% of nursing practice time is spent documenting care
  • Nurses document an average of one data point every minute
  • There are more than 600 manual flowsheet data entries into electronic health records (EHRs) during a 12-hour shift

Time-consuming documentation

Everyone agrees that capturing and documenting clinical data is essential. The guidance provided within nursing flowsheets plays a significant role in improving care delivery and making appropriate care decisions. Yet health systems struggle to manage this sizable body of content.

As stated in the study, the data being collected and documented should be “clinically pertinent, of high quality, efficient and usable, support multiple downstream uses as a byproduct of recording care delivery, enable shared decision-making and collaboration, enable collection and interpretation of information from multiple sources, and be automated whenever appropriate.” I doubt you would find anyone arguing with that list.

Unfortunately, the impact of all this documentation on nurses ― who are some of the largest users of health information technology ― is significant. The study quantified the number and frequency of data points entered into an EHR by bedside nurses working in acute care general medicine units and intensive care units (ICUs) for 12 months. The researchers discovered that, on average during a 12-hour shift, nurses perform 787 to 852 flowsheet data entries in an ICU and 667 to 930 flowsheet data entries on an acute care floor. That’s a lot of data.

Of course, nurses also perform other types of EHR documentation not included in the study, such as medication administration, plan of care, patient education and narrative notes. Other research, cited in the study, found that nurses spend approximately 21 to 38 minutes writing narrative notes every day.

Lag time

The time lag between when clinical measurements or observations are made and when they get reported in flowsheets varies. These delays can have a negative impact on patient care. Getting accurate and timely information into the hands of the care providers is essential for patient safety.

Average Entry Time Graph (Flowsheet Documentation)

Fueling the burden

What’s driving this overwhelming amount of documentation? In one word: Variation. The information captured in nursing flowsheets is constantly changing. Flowsheet rows are customized, causing duplication. Multiple versions of a single flowsheet row can send users down different pathways. These duplications persist within the EHR, providing outdated guidance long after best practices have been updated.

Decreasing variation

Several professional organizations and government agencies are taking a closer look at ways to decrease the documentation burden so nurses can spend more time interpreting, annotating, synthesizing and communicating patient information. This topic is a focus across our industry. I invite you to listen to this informative webinar to hear a conversation I had with some experts who are having success addressing the problem of nursing workflow and optimizing documentation.

In Part 2 of this blog series, we’ll explore a few examples of how flowsheet variation affects patient care ― and what can be done about it.

Brita Hansen, M.D., is Chief Medical Officer of LogicStream Health. She began her career as an internal medicine hospitalist physician after receiving her undergraduate degree at NYU and her Doctorate of Medicine from the University of Minnesota School of Medicine. She served as Chief Health Information Officer for the Hennepin County Medical Center before joining LogicStream Health.

Topics: Patient Safety, Flowsheets, Nursing Documentation

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Brita Hansen, MD, is Chief Medical Officer at LogicStream Health. Dr. Hansen is also a practicing internal medicine hospitalist and has served as a healthcare system executive, most recently as Chief Health Information Officer at Hennepin County Medical Center in Minneapolis. Dr. Brita’s Blog covers a range of topics, including:

  • Appropriate Utilization
  • Clinician Engagement
  • Clinical Process Performance & Improvement
  • Healthcare Information Software & Technology
  • EHR Optimization
  • Clinical Decision Support
  • Healthcare Patient Safety & Quality

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