Documentation Guidlines: Part 2

Continuing the discussion of developing documentation guidelines; our team conducted an environmental scan to learn what others have done and were doing to address the issue of documentation burden. I was pleased to discover a number of articles written related to issues surrounding documentation burden.

There were common themes in the literature. For example, each reported that they were responding to documentation burden as a nurse dissatisfier. All expressed how they examined the problem and associated issues. Most reported their assessment involved metrics such as click, query, and screen counts.  Others reported metrics related to time to complete a screen or function such as the admission assessment.  Never did we find anyone describing their assessment of the nurse's documentation level of effort as good or expected.

A common tactic to combat documentation burden in the literature was to develop guidelines for reviewing EHR queries requests. As we examined our facility we noticed a trend to have queries added in reaction to practice issues. It seemed we were attempting to teach nursing or somehow control for bad actors by adding a query to "guide" the user.  We realized that is not the purpose of an EHR and we had unwittingly contributed to our documentation burden with this practice.

We decided to develop guidelines of our own to inform and review both new and existing EHR queries. Queries requests would need to be evaluated against guidelines.  The draft guidelines our clinical informatics group put forth are:

• Assume that nurses are ethically and clinically competent
• Collect data that inform clinical care and supports nursing workflow efficiencies (nursing care planning, clinical decision making or nursing outcomes).
• Construct data and queries to support evidence-based practice
• Automatic data capture whenever possible for bedside devices (Cardiac monitors, ventilators, IV pumps, etc)
• Required by mandatory regulations 

I would be interested if anyone would be willing to share their guidelines or wish to comment on our draft.

Documentation Guidelines

Documentation is a mainstay of nursing practice.  Even as students we were taught to record the clinical activities and observations.  Nursing notes can be traced back to Florence Nightingale. Clearly, nursing documentation has been around a long time.  We use nursing documentation to identify clinical trends and patterns that inform nursing care planning and decision making. As we adopted the electronic health record (EHR) we began increasing our data collection with the promise that electronic data would be usable and shareable. Unfortunately, that assumption hasn't proven to be true. Some have described today's health record as data rich, information poor and given this phenomenon the name DRIP Syndrome (Goodwin, 1996). 

I find this phenomenon present in the hospital where I practice.  My colleagues have reported they too experience the frustration of DRIP Syndrome. It seems that just because we could add data fields; we did.  The result is an explosion of data capture requirements creeping into our EHR with little improvement in clinical outcomes or observations. The unintended consequence of randomly adding data fields is the reduction of the clinical nurse's capacity to provide direct nursing care.

The purpose of documentation was never to replace time spent in clinical care. Documentation was to collect and trend clinical data that informed observations regarding successful therapies and outcomes. How do we get back to meaningful documentation that informs nursing care planning and decision making? The approach our facility is taking is to establish guidelines that data capture must meet before it is added to the EHR.  Additionally, we plan to establish a review process to determine if an existing data field continues to meet the guidelines.  I am wondering if anyone else is working on a similar project?  I plan to share our work and hope others will do the same. 

Reference:
Goodwin, S., (1996). Data rich, information poor (DRIP) syndrome: is there a treatment? Radiology Management May-Jun;18(3):45-9.