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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.

Borchers (1999) shared that the best way to get nurses to improve their documentation is by having them become actively involved with the process changes.

Much 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.

            According to Allan and Englebright (2000), after making improvements in their computer-based system, computerized documentation proved to save nursing time, documentation became consistent, nursing satisfaction improved, and physician complaints declined.  Even though there were problems that became apparent during the phase-in process, the nurses supported the computerized documentation. 

            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.

Background Information

            At 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.

It 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, yet another nurse would use the patient care note screen to document a narrative note because she thought that the daily shift assessment screen did not allow for enough pertinent information.

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.

Another 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 nightmare. 

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.

    Documentation 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

            The 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.

One 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 become.

The “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 prompts to assist the nurses in completing the appropriate information.  A recall key can be used to pull up information that has already been documented during the patient’s last stay.  This assisted in decreasing the amount of time documenting.  The nurse verifies the information that comes up to make sure that is the most recent, accurate data.  This can  take as little as five minutes to 15 minutes to review and revise, depending on the patient’s condition. 

The “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. 

Other 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 diagnosis/diagnoses to update the patient’s plan of care.  This change has assisted the nurses in following a standard of care: “Every patient will have a current plan of care documented in the patient record from admission to discharge and nursing will contribute to this plan of care.”   As a patient’s status changes, it is addressed in the “daily shift assessment screen”, which then prompts the plan of care to automatically identify the actual problem to be addressed.

Another 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 automatically calculated.  The ultimate goal is to have the red screen appear when the Braden Skin score is 16 or less.  This will alert the nurses specifically to any potential skin breakdown problems.

Several 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.

It 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 routines.

            Staff 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 improvements. 

            The 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.   

            One 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. 

            All 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 more accurately.


            There 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 needs.  Physicians 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.