Improving Nursing Documentation in a
Computer-based Inpatient Hospital Setting
Dawn Gapko RN, BSN
In 1998, Howard Young Medical Center, a small rural hospital, decided to introduce computerized nursing documentation, a nursing module combined with the hospital-wide computer system, to the nursing staff. The nurses had been familiar with the computerized system using order entry, which allowed access to the laboratory, radiology, and other disciplines, such as dietary, physical therapy, occupational therapy, just to name a few. The thought of computerized nursing documentation seemed overwhelming to the staff. The organization made the decision to have a computer in each patient’s room for the purpose of making documentation easier and faster to carry out. It was believed that nurses could spend more time at the patient’s bedside, which would allow the nurses to improve the content of documentation. Instead of documentation becoming easier and quicker, documentation became fragmented, which made patient care appear fragmented. It was difficult to get a clear picture as to what was happening to the patient. No one person could get a good handle on the patient by just looking through the computerized chart. Due to the difficulties in retrieving complete and accurate documentation, the Clinical Information Specialist, the Collaborative Care Guide Clinician, along with the Documentation group at Howard Young Medical Center, worked diligently on making the computerized documentation clear, concise, and easy to obtain.
Review of Literature
Accurate and complete nursing documentation has been emphasized to nurses since the Florence Nightingale era in the mid-1800s. It has become even more crucial
today when dealing with reimbursement and quality concerns (Webster, 1998). Insurance companies and Medicare are sending out denial letters relating to poor chart audits. This creates more work for the Quality Department or Utilization Review by causing the need to reevaluate the charts for completeness. Another reason for the importance of complete and accurate nursing documentation is due to the rise in litigation. The old saying “If it’s not documented, it’s not done” still holds true today. Griffiths and Hutchings (1999) shared that nurses may feel that their written documentation is not valued. Instead, it is the verbal communication between disciplines, which they feel enhances quality of patient care. Even though verbal communication can not be undervalued, it is the written documentation that demonstrates the nurse’s worth.
According to Griffiths and Hutchings (1999), nurses expressed the reasons for
lack of complete and accurate documentation was related to problems such as
under-staffing, high census, working overtime, and also not knowing exactly what
needs to be documented. Despite these reasons for not documenting completely and
accurately, nurses need to realize that stringent rules and regulations by
federal and accrediting organizations indicate that complete and accurate
documentation is an expectation.
(1999) shared that the best way to get nurses to improve their documentation is
by having them become actively involved with the process changes.
of what nurse’s do is based on attitude and self-motivation.
If management could tap into the nurse’s creativity, not only would
they assist in making positive changes in documentation, they would also be
advocates toward those changes.
to Allan and Englebright (2000), after making improvements in their
Nursing documentation needs to be complete and accurate as well as easily
retrievable for the other disciplines using the information.
Documentation needs to flow easily across the continuum of patient care
(Brunt et al. 1999). Brunt’s et
al. (1999) project focused on the acute care setting , which included
“pre-admission, acute care, and post-discharge”.
The use of computerized documentation allows for this documentation to
flow easily for all disciplines and makes the retrieval of patient information
much easier to obtain.
Howard Young Medical Center computerized documentation was brought into the
system in 1998. It was felt that
computers were going to decrease nursing time spent documenting and increase
nursing time spent with the patient. Instead, documentation became a major concern for the
physicians, nurses, as well as the other disciplines involved in the patient’s
care. Many concerns were
found to affect documentation.
was found that the computer training courses did not allow for enough time for
the nurses to learn what was needed to complete the computerized documentation
completely and accurately. What
happened was documentation methods became creative. For example, one nurse would use the daily shift assessment
screen for the usual
Documentation was found to be inconsistent and fragmented from chart audits that had been done by the Care Guide Clinician. It was found that documentation was lacking in such a way that all aspects of care were not assessed every eight hours or as patient conditions changed. It was found that nurses were not documenting consistently in the same place, which made it difficult to retrieve patient information as well as get a clear picture as to what was happening with the patient. Instead of saving time, it was felt by the nurses that it took more time to document. Physicians voiced their concerns on the nursing documentation. They had a difficult time finding the information that was needed to help them get a feel for how the patient had done over night. Depending on which nurse the physician asked, he or she would get a different answer as to where to find the results. The physicians had become so frustrated that they gave up looking for the documentation in the computer. Instead, they ended up seeking out the nurses to obtain a verbal report on their patients.
concern was the duplication in documentation.
Nurses were putting information into two or more different screens
depending on their own comfort level in documentation.
Instead of documentation becoming easier and quicker, it had now become a
Documentation guidelines and/or policy and procedures were not developed yet. Nurses did not have documentation as to what was expected from them relating to nursing documentation. The nurses’ felt confused and frustrated because they felt what was suffering was patient care. More time was spent asking questions and charting instead of spending time at the patient’s bedside.
on the patient’s plan of care was a concern because it lacked completeness. There was no way to monitor if the patient was involved in
his or her plan of care. Nurses
have a standard of care to provide to their patients.
Each patient required a current plan of care documented in the patient
record from admission to discharge and nursing needed to contribute to this plan
of care on a continual basis. Somehow
this process was lost.
Improvements Made in Computerized Documentation
Clinical Information Specialist, Care Guide Clinician, and the Documentation
Evaluation Team met to discuss the difficulties in documentation and what
improvements could be made. The
group assessed every screen the nurses documented in and made improvements based
on nursing input.
area the nurses stated improvements were needed was in decreasing the amount of
time it took to document using the “plan of care screen”. The Clinical Information Specialist built the care guides and
the patient’s plan of care into the computer system. With a push of a button, the standard plan of care is filed.
This takes less than 30 seconds. The
nurses have stated that they really like how fast and easy this process has
“initial assessment screen” was found to be cumbersome and time consuming
for the nurses to fill out. Improvements
were made to the screen, which included specific
“daily shift assessment screen” requires documentation every eight hours or
more as the patient’s condition changes.
This screen has been revised several times in response to nurse’s
suggestions for improvement. The
most recent improvements were made in July 2000.
After each body system, such as cardiovascular or gastrointestinal, there
is a patient note (PN) box where the nurses can put a N (no), which means no
note will be made on this body system. Y
(yes), which means a patient note will be made but not until the nurses have
completed their assessment. Or I
(immediate), at which time the patient note screen automatically pops up to
allow the nurses to make an immediate patient note regarding the appropriate
body system. This change has been a
major improvement. Nurses have
given positive feedback stating that it helps them to document the important
information right away instead of needing to go back into the screen to find out
what they needed to document.
changes made to the “daily shift assessment screen” included patient
specific plans of care. After this
screen is completed and filed, another screen automatically opens and identifies
actual patient problems that can automatically be transferred to the present
plan of care. The nurse can decide whether or not to add the
area in which changes were made was on the integumentary assessment.
Despite having the integumentary assessment located in the daily shift
assessment screen, it was found that documentation was poor.
The Braden Skin Score, which calculates the risk of a patient developing
a pressure sore, is used to address when the nurse need to place the patient on
a specialty bed. The Braden score
was noted to not change throughout the patient stay.
However, some of the patients’ conditions did change, which would have
altered the Braden score. From this
data, prompts were made more specific for the nurses to key into the various
types of skin changes. For example,
specific words such as abrasions, ecchymosis, open sores, scratches,
lacerations, pressure ulcer, and ulcer stage were added.
If (Y) is entered for any of the above mentioned, the patient note box
will automatically open up for the nurse to document the specifics.
Under ulcer stage, the nurse can press the look-up key.
This allows a nurse to read the definition of each ulcer stage.
If (Y) is entered under pressure ulcer, a red screen will automatically
appear with the words “Patient requires the use of a specialty bed.”
This reminds a nurse to prepare to have a patient moved onto the
appropriate bed, thus preventing potential skin breakdown and it also improves
the patient’s plan of care. The
Braden Skin score is
improvements were made with the discharge instruction’s screen and with
creating canned text where a nurse uses a specific key and types “DIS”.
This allows a pre-typed discharge note to appear that includes time and
date of discharge, patient received and signed discharge instructions, mode of
discharge (whether ambulatory or wheelchair), discharged with whom, and
patient’s status at time of discharge. All
a nurse needs to do is fill in the blanks to make the note patient specific.
This has also reduced the amount of time required to document because the
nurses do not need to think about everything that needs to be included in the
discharge note. It is now right
there for them to complete.
In-House System Improvements
Nurses felt their concerns were finally being heard. The changes in computer documentation had been received in a positive manner. The more these changes were made to meet patient and nurses needs, the more input nurse’s gave for future improvements. The nurses stated feeling the positive changes. They have seen less duplication of interventions, which has decreased the time spent on documentation and increased the time spent with patients.
was realized that nurses needed further education on computer documentation.
The hours for nursing educational inservices for new nurses were
increased. If nurses felt
uncomfortable after their scheduled time, another eight-hour session was added.
It was agreed
that staff needed to have a working knowledge of the nursing assessment
meetings were used to educate and reeducate the nurses on proper documentation.
If scheduling allowed, the Care Guide Clinician met with the staff on a
monthly basis to keep them updated on the data collected regarding the
improvements made in their documentation, as well as on areas where improvement
was needed. This time was used to
gain input from the staff as to what suggestions they had for future
Documentation Team has been working on specific guidelines for each of the
nursing screens. Each nurse will
document in the correct screen, the same screen as everyone else.
There will no longer be any second guessing as to where one documents
information. Once all the
guidelines have been developed, one policy will be developed to address the
guidelines for documentation.
area that had caused duplication in documentation was the use of the
interventions. The interventions
not used have been deleted. Specific
interventions that are required have a comment screen attached to allow the
nurses to automatically document their response.
nurses are required to do a chart audit. This
practice is used as a learning tool. As nurses realize that their documentation
is being monitored and that they will be approached if documentation is not
accurate, there is a more concerted effort made in completing the documentation
have been many positive changes made to the nursing documentation.
There will continue to be changes made as the nurses continue to bring
forward their concerns.
Prompts have been created to remind the nurses when a specialty bed is
recommended for a patient with potential skin breakdown.
Pop-up screens appear to remind nurses to document on patient teaching
find the nurses notes to be more accurate and complete.
Nurses are starting to become familiar with the changes. Many positive responses have been received from nurses stating that they can tell the difference in the amount of charting as well as decreased time associated with documenting. It is realized that there are still areas in which improvements can be made. The Clinical Information Specialist is learning how to build multiple nursing screens in the computer system. He is also learning creative methods to decrease the number of keystrokes used for documenting information. As future improvements are being looked at for decreasing time spent documenting on the computer the goal is for increasing nursing time spent at the patient’s bedside.