Optimizing Nursing Documentation

By Jessica Campbell, DNP, RN, Clinical Informaticist, LogicStream Health & Tiffany McCauley, MSN, RN, Clinical Executive, Elsevier

How process, evidence and technology come together to improve coordination of patient care, increase efficiency and boost clinician satisfaction 

Hospital systems rely on nurses to do more than ever before. Beyond caring for patients, nurses are tasked with helping to maximize performance in the midst of changing reimbursement models, achieve regulatory compliance, promote better outcomes and increase patient satisfaction. Nurses are under an immense amount of pressure to provide coordinated patient care. Sometimes, the biggest challenge is feeling as though the tools designed to help capture and share information are part of the problem. 

A major problem is lack of standardization. Organizations attempt to meet everyone’s needs by creating specific resources to accommodate individual clinicians or departments. The lack of consistency paired with excess requirements leads to variability in care.

The good news is that optimizing clinical documentation can yield significant benefits, including improvements in patient care and safety, clinician satisfaction and efficiency, as well as a reduction in errors and unnecessary procedures. 

 A time-consuming task

While the overwhelming burden of nursing documentation is a well-known challenge in healthcare, a recent study, Quantifying and Visualizing Nursing Flowsheet Documentation Burden in Acute and Critical Care, helped quantify the problem:

  • 19 to 35 percent 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

The study examined 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.

In addition to items measured in the study, other documentation requirements consume additional time, such as medication administration, plan of care, patient education and narrative notes. For example, other research findings cited in the study showed that nurses spend approximately 21 to 38 minutes writing narrative notes every day.

Fueling the documentation burden

Everyone agrees that capturing, documenting and disseminating clinical data is essential. It’s also clear that there’s a need to improve how it’s done, including the processes and tools involved, since a major contributor to the nursing documentation burden is unnecessary variation. 

“Nursing documentation as a whole is frequently enhanced and expanded upon, flowsheet related content is no exception,” explains Jessica Campbell, DNP, RN, Clinical Informaticist, LogicStream Health. “Often, flowsheet rows are customized, causing unnecessary variation and duplication. As a result, multiple versions of a single flowsheet row can send users down different pathways. Unfortunately, these duplications persist within the EHR where they go on to deliver outdated and often competing guidance long after evidence-based best practices have been revised.”

Contributing to fragmented care

“Traditional workflows used by nurses and then the rest of the care team often contribute to fragmented care,” says Tiffany McCauley, MSN, RN, Clinical Executive, Elsevier. “This can happen due to the siloed-nature of healthcare settings, such as differences between the ambulatory and acute care settings, or varying approaches used by various specialties, but we also see fragmented care with a single department. The reason is that each discipline, or interprofessional teammate, has their own set of tools they use, which live in the EHR but never get merged together.”

For example, if a physical therapist (PT) has just been at the bedside visiting a patient, how does the nurse tap into the information coming out of that visit? Can the nurse easily find out what the PT thinks about how the patient is doing and the care plan they have put in place? Are those insights, which are essential to ensure patient safety, brought to life within the nursing workflow? Or does the nurse have to search the EHR to find it? Unfortunately, it’s often the latter. That inefficiency is a significant burden given how busy care teams are. If the nurse isn’t aware that the PT goal for the patient is walking 50 feet that day with a standby assist, the nurse might have the patient walk more – or less – and do so unassisted. 

Consider how discrepancies like the PT example are multiplied throughout the day for every patient because insights from each member of the care team all exist in different parts of the EHR. They’re all guided by different workflows, some of which may be driven by outdated evidence. It paints a compelling case of the urgent need for optimization.

“Care fragmentation increases patient healthcare costs while diminishing the quality of care,” says McCauley. “In this environment, important health issues are not properly addressed, patient health outcomes are at risk, and there is an increased likelihood of unnecessary or potentially harmful health services.”

Data shows that 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.

Source: LogicStream Health 

Complex patients

Documentation optimization is even more critical when caring for patients who endure one or more chronic conditions and are particularly at risk of fragmented care. That’s because caring for these patients typically involves multiple participants who each provide specialized knowledge, skills, and services. 

When fragmented care is provided to patients with complex conditions, they encounter higher rates of emergency department visits, more hospital admissions and greater healthcare costs. A 2018 study by The Commonwealth Fund, Whether Fragmented Care is Hazardous Depends on How Many Chronic Conditions a Patient Has, found that patients with one or two chronic conditions and highly fragmented care were 13 percent more likely to visit the emergency department than those who had the least fragmented care. A 2015 study in the American Journal of Managed Care, Care Fragmentation, Quality, and Costs Among Chronically Ill Patients, found that patients with highly fragmented care had an average total cost of $10,396 over a 35-month period, compared to an average cost of just $5,854 among those who received the least fragmented care during the same period of time.

So, what needs to be done to fix this problem and provide coordinated care? One answer is to optimize processes and systems to reduce variation and ensure clinicians are using up-to-date, evidence-based guidance. 

Evidence-based workflows

“The volume of available medical knowledge is doubling every few months as new guidelines are released and standards are updated,” says McCauley. “It’s unrealistic for any care team to keep up with all the relevant, evidence-based information that impacts patient care. That’s why the integration of evidence-based medicine into clinical workflows is essential. Its application at the bedside drives ongoing improvements in clinical decision-making and, ultimately, overall patient outcomes.”

Evidence-informed care has many benefits. It reduces unwanted variability across the continuum, drives the plan of care in a meaningful manner and helps achieve regulatory compliance. Using tools such as a combined evidence-based comorbidities template, for example, can help reduce documentation fatigue for clinicians and improve continuity of care regardless of the healthcare setting.

Technology solutions

So how do hospitals streamline their systems to remove variation and consistently deliver up-to-date, evidence-based guidance? First, it helps to understand how the content inside the EHR tends to evolve, and why.

“Hospital systems make multiple changes in their EHRs every day,” says Campbell. “Sometimes those modifications are based on the unique needs of a specialty area, but other requests for changes may be rooted in how a team in a particular nursing department 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.”

Campbell shared a few examples of the unintended consequences of workflow modifications:

  • Combining too much information in a single row. That sounds like 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.
  • 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 a deviation from the desired clinical process. It also makes it much harder to aggregate data and decreases the 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. Because guidelines are constantly changing, it’s essential to ensure that old information is removed when new evidence is added.

To optimize nursing documentation, health systems are using clinical process improvement solutions that provide data-driven 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, hospitals can make necessary adjustments to their EHR. In addition to speeding up the documentation process, the removal of unnecessary flowsheet duplication helps the entire clinical team ensure continuity of care when the patient is transitioned to another part of the health system.

Impact of coordinated care

Optimizing and standardizing the process of collecting and disseminating information to help drive coordinated care is essential. Why? Consider the following evidence of the impact of fragmented versus coordinated care.

Uncoordinated care leads to communication failure, higher drug costs, duplicate testing, a lack of patient engagement and higher readmission rates. According to the American Nurses Association, patients with uncoordinated care experience 75 percent higher costs than patients with coordinated care. The American Journal of Managed Care reported that fragmented care leads to twice as many primary care visits and six times as many specialist visits.

Patients experiencing highly fragmented care have twice as many primary care visits, and 6 times as many specialist visits.

Source: The American Journal of Managed Care, May 2015. 

In contrast, patient-centered care coordination can have a compelling impact on patient outcomes and healthcare costs. Interprofessional collaboration and continuity of care are associated with better preventive care, fewer emergency department visits and hospital admissions, and better patient experience. 

The power of interprofessional collaboration: 

Source: Journal of Interprofessional Education & Practice. ScienceDirect. Jun 2017.

Clinician satisfaction and culture

Clinicians are hungry for a change. Reducing the documentation burden on nurses lets them focus on the more rewarding aspects of their job. A recent study revealed that 85 percent of clinicians agree that coordinated, collaborative, inter-disciplinary practice increases their job satisfaction. 

As with any change, culture is a key component of successful system optimization. Technology tools alone aren’t going to drive evidence-based, interprofessional practice. From leadership to members of the clinical team, everyone must embrace the philosophy behind the tools to optimize and sustain an enhanced professional practice. 

“If people don’t understand how to use the evidence-based content and apply it to their day-to-day work, then it’s not solving the issue of fragmented systems,” explains McCauley. “It’s important to achieve a balance by implementing the right content and technology while focusing on the clinical team’s perspective and working from there to achieve the multi-disciplinary collaboration required under emerging quality-based care models.”

“Technology solutions are now available to assess the clinician workflows and understand how care is being provided. By evaluating workflows alongside outcomes, health systems are able to understand what the evidence-based best practices are and how they can be implemented,” said Campbell. “More importantly, once those workflows are implemented, measuring and management of those workflows as the evidence changes are ways we can have a significant positive impact on patient outcomes.”

About the Authors

Jessica Campbell, DNP, RN, is a Clinical Informaticist at LogicStream Health. Campbell is an informaticist and registered nurse focused on quality of care, improving documentation standards and clinical process improvement. As a registered nurse she provides care in the perioperative and critical care specialties. Campbell earned her Bachelor of Science in Nursing from the University of Wisconsin-Eau Claire and her Doctor of Nursing Practice in Nursing Informatics from the University of Minnesota-Twin Cities.

Tiffany McCauley, MSN, RN, Clinical Executive, Elsevier Tiffany McCauley, MSN, RN serves as a Nursing Executive with Elsevier Clinical Solutions. In this role she collaborates with health care systems, academic centers and physician practices to reduce variation in care, standardizing practice and improving patient outcomes through the application of evidence-based decisions at the point of care. Prior to joining Elsevier McCauley lead the development of nursing and patient education programs at a number of leading community-based health care organizations. Her focus has been on improving staff engagement and the patient experience by leading change initiatives related to standardizing clinical knowledge and practice while effectively engaging patients in their care across care settings. McCauley believes this is a key component in improving the healthcare experience for patients.