Electronic Nursing Documentation: Charting New Territory

Laura A. Stokowski, RN, MS

Disclosures

September 12, 2013

In This Article

EHRs Take Too Much Time

Before EHRs were implemented, they were touted as a huge step forward in patient care. They were supposed to be more accurate, safer, timelier, and faster. Computers were going to free up nurses to spend more time with patients.

Instead, report many nurses, documentation is taking longer than ever. One nurse believes that since going live, EHRs have added 3 hours to a 12-hour shift. The extra time that EHRs take has many origins -- endless logging in and out; paging through unnecessary screens; duplicate entries; trying to find where to chart something; slow, cumbersome systems; and increased mandatory documentation. The latter complaint was frequent. One nurse commented that EHRs require nurses to chart not only what they did, but also what they didn't do -- for example, "didn't put in a Foley." With computers in the patient rooms, nurses often can't concentrate on the task at hand; they are constantly being interrupted by patients and visitors while they are trying to chart, and consequently, charting takes longer.

To save time, some healthcare providers take advantage of the "copy-and-paste" feature of EHRs, which might be a double-edged sword. If the person who copies and pastes does not verify every word or data point, it is alarmingly easy to perpetuate errors in the chart, a problem that many readers have already identified in actual patient EHRs.

And the time saved by CPOE in not having to write verbal orders, or interpret illegible orders, has been lost in other ways. Some nurses report that CPOE has reduced face-to-face communication with physicians, so they have less understanding of the plan of care for patients, and they spend more time double- and triple-checking orders to make sure they don't miss something.[3]

The extra time that it takes to chart with EHRs must come from somewhere. Fundamentally, nurses do not consider documentation time as time spent providing patient care.[4] Knowing that they will be judged on their documentation rather than their care, many nurses feel that patient care has suffered. One nurse even said (tongue-in-cheek), "In reality, we don't need to do anything at all for the patient, as long as we document that we did."

A far more common complaint is that "we are nursing the chart rather than the patient." "I never thought I would see the day when a machine would need to be cared for more than my patient," commented a nurse. But rarely has staffing improved to compensate for the increase in documentation time. "We have the same nurse-to-patient ratios as always, but signing in and out of a computer and documenting every little thing we do takes so much more time. That time is taken away from patient care. It's pathetic to see us all lined up at computers instead of caring for patients!"

Or lining up at computers after the shift ends. Our informal EHR survey found that in the past 6 months, 72% of respondents had stayed after their shift to finish charting (46% occasionally, 24% frequently, and 9% almost every shift). Although more than one half of respondents were paid, 21% said that they were "off the clock" when they stayed late to chart. A nurse practitioner wrote, "You have the choice of garbage in and getting out on time, or doing a decent job and working longer but uncompensated."

Reasons given by readers for not being able to complete their charting by the end of the shift were fairly evenly divided between insufficient staffing (too many patients for each nurse), too many other responsibilities and interruptions, and unrealistic/excessive documentation requirements with EHRs. Six percent of respondents blamed computer access problems. Inefficiency or poor computer skills were cited by less than 1% of respondents, despite the fact that 55% of the respondents were older than 50 years.

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