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The Overwhelming Burden of Nursing Documentation - Part 2

Posted by Dr. Brita Hansen on Aug 1, 2019 12:01:23 PM
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Aug. 1, 2019 Nurses spend between 19% and 35% of their practice time documenting care. That was one of the insights shared in Part 1 of this blog series examining the amount of time nurses spend recording clinical data in electronic health record (EHR) flowsheets.

Part 1 highlighted the findings of a recent study, Quantifying and Visualizing Nursing Flowsheet Documentation Burden in Acute and Critical Care. Today, we’re exploring a few examples of how flowsheet variation reduces efficiency and affects patient care ― and what can be done about it.

Root cause

Electronic health record content is frequently changing and growing, including customizations to flowsheet rows. This impacts the information that is captured and the clinical decisions that are made. Hospital systems make multiple changes in their EHRs every day in response to requests from people across a variety of departments. Sometimes those modifications are based on the unique needs of a specialty area, but other changes may be rooted in how a team on a particular nursing floor prefers to interact with the system. These changes are made with the intent of increasing efficiency, but the overall impact often is just the opposite.

The reason is that flowsheet customizations cause duplication. The result can be multiple versions of a single flowsheet row that send users down different pathways. Here are a few examples of customizations gone awry that we’ve seen in our customers’ systems:

Combining too much information in a single row. That sounds like an efficiency, but instead is overwhelming and impacts a nurse’s cognitive workload. When multiple options for assessments and interventions are combined in a single row, nurses are less certain about what they’re expected to document. For example, in the case of one customization focused on dressings, within a single row nurses were asked about three different interventions of the wound:

    • The dressing assessment (whether the dressing was dry or moist, if the dressing was intact, whether the wound/incision was healing, etc.)
    • Dressing intervention (did they redress it, reinforce it, remove the dressing, etc.)
    • Wound/incision intervention (put ice on the wound/incision site, apply/hold pressure if wound/incision is bleeding, etc.).

This combination of concepts causes added confusion due to the need to remember all the documentation types included in the row but not intuitively related or relayed through the flowsheet row title. In the end, mistakes can happen.

Renaming flowsheet rows. In some cases a flowsheet row, such as for catheter intervention, gets duplicated under a different name but has the same answers as the original row, so nurses end up using both options. This lack of consistency causes loss of standardization and creates deviation from the desired clinical process. It also makes it much harder to aggregate data and decreases visibility of documentation across care units and from nurse to nurse. This is often caused by personal favorites or requests from individual clinicians or departments that deviate from the hospital-approved standard.

Persistence of outdated guidance. Customized flowsheet rows often include guidelines that are no longer relevant or appropriate, but the health system doesn’t realize those rows still exist. Long after best practices have been updated, these duplications persist within the EHR, providing outdated guidance that puts patients at risk. Because guidelines are constantly changing around everything from VTE documentation practices to indications for urinary catheter insertion and removal, it’s essential to ensure that old information is removed when new evidence is added.

All this variation consumes nurses’ time, producing inefficiency. It also results in unnecessary ― and potentially harmful ― variation in patient care.

Data-driven solutions

To identify duplication within EHR flowsheets, hospital systems need data-driven analysis. To optimize nursing documentation, health systems need clinical process improvement solutions, like LogicStream Health’s platform, that provide insights into the extent of duplication, frequency of changes and comparison with best practices to determine which guidance has the most clinical value. Armed with that information, they can make necessary adjustments to update their EHR to remove variation and ensure practices align with current standards of care.

Data-driven solutions also can help health systems dig deeper into EHR content and utilization, without having to request extensive reports, to:

  • Improve patient safety by measuring nursing care by department, hospital or clinic
  • Measure flowsheet utilization by hospital, department, care provider or DRG
  • Quickly identify variation in care by hospital, department or nurse
  • Track and monitor documentation patterns including the time between when nursing data is collected and when it is recorded in the EHR
  • Identify flowsheets that are never or seldom used and eliminate the need to maintain unused content

Nursing effectiveness

Removing unnecessary flowsheet duplication not only helps speed up the documentation process, but it also helps nurses capture data more accurately so the entire clinical team can provide better care. When nurses are documenting interventions, it’s essential the information being collected is clinically relevant and up-to-date with current best practices to provide the most accurate picture of the patient. That picture informs the next steps in the care process and helps ensure continuity of care when the patient is transitioned to another part of the health system.

In Part 3 of this blog series, we’ll take a look at how some leading health systems have successfully optimized their nursing documentation workflows with impressive results.


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, 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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