By Mark D Sugrue, RN-BC, HIMSS Nursing Informatics Committee Chair and
Director at PricewaterhouseCoopers
“In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance, have I been able to obtain hospital records fit for any purpose of comparison. If they could be obtained, they would enable us to decide many other questions besides the ones alluded to. They would show subscribers how their money was spent, what amount of good was really being done with it, or whether the money was not doing mischief rather than good.” Florence Nightingale, “Notes on a Hospital,”1873
The documentation of patient care is one of the most vital functions of the healthcare team.
At the individual patient level, clinical documentation provides the mechanism to translate into words the patient’s unique needs and the care provided to achieve optimal outcomes.
Accurate clinical documentation helps to ensure safe transitions of care across all practice settings while simultaneously providing an opportunity to identify trends and subtle changes in the patient’s condition or behavior.
Simply put, clinical documentation tells the patient story.
Yet, it could be argued that medical records today, whether paper or electronic, are no better at telling the patient’s story than they were when Florence Nightingale provided care to her patients in the 19th century, and first noted the lack of information available in hospital records.
While admittedly anecdotal, there is a growing opinion among clinicians from all disciplines that modern-day, 21st century documentation has become more and more about completing complex, and often burdensome, data requirements than about describing patient care.
Nowhere is the absurdity of modern clinical documentation more apparent than in nursing. Complexity in charting patient care has risen to the point where the nurse is now spending a disproportionate amount of time on documentation-related activities.
A 36-hospital time-motion study by Ann Hendrich et al found that medical-surgical nurses spend more than 35% of their time on documentation-related activities. This same study reported that nurses are at the nurses’ station nearly 70% of the time while in patient rooms only 3% of the time. (1)
So, the challenge is upon us as nursing informatics professionals. We must design and implement solutions that provide opportunity to support the delivery of care while not losing the ability to articulate the story of our patients and families.
Share your thoughts on clinical documentation, patient care solutions and the patient story here on the HIMSS Blog.
(1) Ann Hendrich et al, “A 36 Hospital Time Motion Study: How Do Medical Surgical Nurses Spend Their Time?,” The Permanente Journal, 2008, Vol. 12, No. 3.