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The Overwhelming Burden of Nursing Documentation - Part 3

Posted by Dr. Brita Hansen on Aug 15, 2019 1:45:44 PM
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Aug. 15, 2019 - Nursing documentation is a necessary but overly complicated and time-consuming task. It’s a common problem worthy of a closer look, so in Part 1 of this blog series, we examined the findings of a recent study, Quantifying and Visualizing Nursing Flowsheet Documentation Burden in Acute and Critical Care.

In Part 2 we considered how flowsheet variation negatively affects efficiency and patient care and explored data-driven solutions for minimizing those variations.

Now in Part 3, we’re delving deeper to see how a couple of health systems have successfully optimized their nursing documentation workflows ― with impressive results.

Cutting through the clutter

Earlier this summer, I participated in a webinar discussion sponsored by the Scottsdale Institute about how to streamline nursing documentation. Clinical documentation is such a hot topic because it’s used to meet all sorts of health system goals, from satisfying regulatory and billing requirements to justifying the work hospitals have done, communicating with others on the care team and even helping to reduce liability.

With so many varied expectations, it’s no wonder hospitals sometimes lose sight of the original purpose of nursing documentation, which is two-fold:

  1. Support the nursing process. This includes assessment, diagnosis, planning, intervention and evaluation. Documentation helps ensure that best clinical practices are followed and that care is delivered in a consistent, reliable manner.
  2. Tell the patient story. Nurses are the experts at telling the patient story, and proper documentation practices capture that information so that others on the care team can understand and respond promptly to provide appropriate patient care.

Standardizing the way nurses record clinical data in flowsheets helps to cut through the clutter that tends to accumulate in electronic health record (EHR) systems and reduces the associated cognitive burden for nurses who have to sort through it every day. During the webinar, two leading health systems shared insights and successes from their nursing documentation projects.

Transforming nursing documentation

At Hennepin Healthcare in Minneapolis, the project team sought to transform the way they approached nursing documentation. They focused on how it reflects the critical thinking of nurses and supports nursing professional practice. At each point in the process, they explored how documentation was being used from the nurse’s perspective, the care team perspective and the patient perspective. They used a combination of observation and data-driven analysis together with external research into best practices and consideration of evidence-based requirements to determine what needed to be documented and how best to capture the information.

They identified significant variation in documentation practices and worked to streamline their approach. As a result, they were able to reduce the number of documentation items for a head-to-toe patient assessment by 48% and cut the number of care plans from more than 400 down to two main plans with 125 supporting criteria-specific care plans. They involved nurses throughout the design, decision-making and usability testing phases of the project. You can hear about that aspect and other keys to achieving their success in the webinar discussion.

Flowsheet cleanup

At UnityPoint Health, the team streamlined inpatient nursing documentation during an intensive two-year project spanning four states, 22 hospitals, 310 clinics, 19 community hospitals and 12 affiliated partners. They discovered that nurses had a predominantly negative view of documentation ― they felt it was of little value in telling patient stories, wasn’t being accessed by others on the care team and even drove noncompliance.

In addition to surveying nurses and informaticists, the team conducted a quantitative review of flowsheet usage and then worked to standardize where and how information was documented in the EHR. Using a phased approach, they introduced changes with setting expectations clearly and ample communication and training. The project yielded impressive results, including a 12% reduction in the amount of time nurses spent charting information in flowsheets. The changes saved an average of 17 hours per nurse each year ― a significant amount of time with 3,000 nurses affected by the improvements.

Clear impact

In both of these examples, streamlining and standardizing documentation has made a big difference for nursing effectiveness. Both health systems credit their success to the involvement of nurses directly in the review process, executive leadership support for the projects and use of data-driven approaches to identify what needed to change. I encourage you to download the slides and listen to the webinar to determine if any of their strategies might be beneficial for your organization.


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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