If Documentation is a reflection of our care - Does it show that nurses make a difference?

14 May 2014 | Deborah Ariosto, PhD, RN, Director, Patient Care Informatics & CNIO, Vanderbilt University Medical Center

nursing documentation
Where is Documentation Heading

Some hospitals have decades of experience with electronic documentation and some are rushing forward to meet regulatory incentives that will bring nursing systems along as an add-on. Current documentation still reflects a forms-based mentality where paper templates are recreated electronically without reusable data and real decision support for nurses.  Quality, Risk and Legal’s insatiable appetite for data is satisfied with our limitless capacity to create new fields in the name of safer care.  Reinforced by “if it isn’t charted, it isn’t done” ensures defensive charting that no one reads.   While many resources have been directed at nursing, few innovations have emerged that support their complex decision making and mobile workflows.  Why, because it is hard.  We need to do better.

The Thinking Work of Nursing

Care is increasingly complex, teams and tasks are many, and resources are shrinking… we have to stop, take a breath, and re-envision how the electronic health record can reflect and support the “thinking work” of professional nurses.

In designing our systems, what is valued most – what nurses do or what nurses think?  The diagnosis is a powerful concept that reflects a synthesis of observations, data analysis and clinical experience.  Each member of the team has the responsibility to contribute to the plan of care those insights that each one was uniquely trained to do.  In this era of shortened stays, emphasis on patient engagement and self-care, outcome driven documentation is critical.  Nursing diagnoses reflects the problems and desired outcomes that individualize the medical plan to the patient.  They are the interstitial glue that helps to ensure the success of the medical plan of care by protecting the patient from injury, infection, immobility while helping them to cope and engage in the self-care journey. 

“Somedays I feel I don’t get a minute to think, and am grateful just to finish all the assigned tasks” is oft heard from nurses.  The thinking work (diagnose, plan, evaluate outcomes of care) is often missing or buried under a ton of measurements, order fulfillment, and defensive documentation. What strategies can help us delegate some of these tasks?

Machines as Care Assistants

Machines are ubiquitous in the clinical environment – getting “smarter” every day with the ability to collect, analyze, display and transmit data.  Devices such as IV pumps, med cabinets, physiologic monitors, ventilators, glucometers, scales and beds probably contain 95% of what nurses currently document.  If we could create an EHR presentation layer that extracted, organized and displayed data without nurses’ intervention, would something be lost?  Would nurses still have the desire and skills to evaluate data and act on data transcribed by machines?  Some argue that the act of writing it down helps the related cognitive processes and is essential.  Some fear that abdicating this work will diminish our value as validators of the data upon which medical decisions are made.  And sometimes practice change, no matter how positive, is really hard.  But we just cannot afford the status quo. 

Deborah Ariosto, PhD, RN
Director, Patient Care Informatics & CNIO, Vanderbilt University Medical Center