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The problem
Electronic health records (EHRs) were expected to make documentation easier, but many nurses report that charting takes time away from patients and contributes to burnout. Before a health system can reduce documentation burden, it needs to know how large the burden is and how to measure change.
How nurses spend their time
In a time-and-motion study of 767 nurses on 36 medical-surgical units, more than three-quarters of reported time went to nursing practice. Within nursing practice, documentation took the largest share, 35.3% (about 147 minutes a shift), followed by care coordination (20.6%) and medication administration (17.2%). Patient care activities accounted for 19.3%, and only 7.2% went to patient assessment and reading vital signs (Hendrich et al., 2008). The study identified documentation, medication administration and care coordination as the main targets for improving efficiency.
Why documentation burden is hard to measure
A scoping review of 35 studies measuring documentation burden among physicians and nurses found no standard, validated measure. Studies used 15 measurement characteristics, including effort constructs (such as EHR workload, work after hours, cognitively cumbersome work and fragmented workflow) and time constructs (such as average time and proportion of time spent). Only 45% assessed the effect of EHRs on clinicians or patients, and 40% mentioned burnout (Moy et al., 2021). Without agreed measures, it is difficult to compare interventions or show improvement.
A measurement plan for a health system
Combining approaches gives a fuller picture:
| Dimension | Measure | Source |
|---|---|---|
| Time | Minutes of active EHR documentation per patient per 12-hour shift | EHR audit logs |
| After-hours work | Documentation completed after the end of the shift | Audit logs and payroll data |
| Volume | Number of flowsheet rows completed per patient per day | Flowsheet data |
| Duplication | Data entered in more than one place, such as pain scores in the flowsheet and a note | Documentation review |
| Experience | Nurses' perceived burden and burnout | A validated burnout survey and focused interviews |
Reducing low-value documentation
- Inventory and justify. Review every required flowsheet row and ask whether it is required by regulation, supports care or is used by anyone. Remove rows that meet none of these.
- Document by exception for routine normal findings, where policy and regulation allow.
- Remove duplication so each data element is entered once and displayed wherever needed.
- Use device integration to file vital signs from monitors automatically, with nurse validation.
- Design with nurses. Test changes with frontline nurses before rollout and monitor for unintended effects, such as missing information that other disciplines rely on.
Evaluation
The project will compare baseline and 6-month measures of documentation time, after-hours charting, flowsheet volume and perceived burden, and will monitor safety measures, such as falls and pressure injuries, to make sure reducing documentation doesn't reduce vigilance.
The DNP-prepared nurse's role
The DNP-prepared nurse leads a nursing informatics council, partners with informatics and compliance teams, and uses data to show leaders how documentation changes affect nurses' time and patient care.
References
Hendrich, A., Chow, M. P., Skierczynski, B. A., & Lu, Z. (2008). A 36-hospital time and motion study: How do medical-surgical nurses spend their time? The Permanente Journal, 12(3), 25–34. https://doi.org/10.7812/TPP/08-021
Moy, A. J., Schwartz, J. M., Chen, R., Sadri, S., Lucas, E., Cato, K. D., & Rossetti, S. C. (2021). Measurement of clinical documentation burden among physicians and nurses using electronic health records: A scoping review. Journal of the American Medical Informatics Association, 28(5), 998–1008. https://doi.org/10.1093/jamia/ocaa325
