Nursing documentation is often cited as a factor for nursing burnout, and many organizations are rethinking the approach to the old philosophy of “If it’s not documented, it didn’t happen.”
Banner Health has embraced a new philosophy of getting their nurses back to the essentials of documentation, leveraging an array of different data analytics and the essential clinical dataset to reduce duplicative and nonvalue-added information in their patient care records.
“We started with reviewing the data on DTA usage and looking at regulatory and policy requirements,” explained Jodi Erpelding, senior director of nursing informatics at Banner Health.
“Then we would take that data to the customers with our recommendations of removing or keeping documentation. If they refused to allow the removal, we needed them to show the policy or regulation that stated we needed to document the element.”
Erpelding, who will speak this week at HIMSS21 about Banner’s ECD journey, which began in 2018, said most organizations have over-designed their electronic health records resulting in a lot of “noise” and non-value-added data elements.
“Nurses are spending more than two and a half hours per patient documenting during their shift,” she said. “If they have five patients, that is almost the entire shift documenting. Physicians are spending time documenting after hours.”
From her perspective, reducing the documentation to move more towards an electronic solution, which also aids in the communication and care for the patient instead of the needed elements for payers, will “bring joy back to medicine” and allow for more time with their patients.
“Challenge the status quo. Take the time to perform deep dives analysis into policies that may set the documentation team up for failure,” she said. “Give the clinicians a chance to do the right thing and then allow the electronic tools to remind them of required and important documentation after a certain amount of time.”
Erpelding also noted it’s important to set boundaries on adding documentation, and if the organization is adding more documentation, decide on what documentation can be removed– another best practice is to have regulatory, compliance and policy teams involved in the ECD discussions.
“Set a threshold of what nursing will document for other specialty teams,” she said. “Even though some changes may only reduce 10 or 20 seconds, stay positive and consider if we save 10 to 20 seconds per patient and a nurse cares for 5-10 patients in a shift that could be a savings of 200 seconds—that’s nearly three and a half minutes.”
“Using Data to Improve the Essential Nursing Documentation” is scheduled for Friday, August 13 from 10:30-11:30 a.m. in room San Polo 3401A at the Venetian.
Nathan Eddy is a healthcare and technology freelancer based in Berlin.
Email the writer: [email protected]
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