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.