Electronic Nursing Documentation: Charting New Territory

Laura A. Stokowski, RN, MS


September 12, 2013

In This Article

Whose Chart Is It, Anyway?

"The purpose of an EHR should be helping the end users (us) to be more efficient in charting and free up time for direct patient care," observed a Medscape reader. However, this nurse reflected, "this has not been the case."

It is no wonder that many nurses feel that they have turned into data-entry clerks. Most nurses are strictly on the "input" end of EHRs, and have little or no experience with the output. It is difficult to appreciate the value of the tremendous amount of information that is processed when all one does is endlessly enter data,[17] especially if the data being entered don't truly reflect what nurses do -- in other words, nursing practice. "Systems seem to be built for the collection of quality improvement data, meaningful use, and physician order entry, not for the ease of nursing documentation," commented a nurse. Another wrote (and others echoed the sentiment), "Charting is about money, accounting, inventory, reports, and many tasks that have nothing to do with nursing."

All of this begs the question: Do nurses and hospitals have different priorities when it comes to documentation, and how can they be brought together?

Traditionally, the purpose of nursing documentation is to facilitate information flow that supports the continuity, quality, and safety of patient care.[2] Over time, documentation has accumulated many other purposes. Even with paper charts, new forms were added from time to time to meet some regulatory requirement or other. Now, EHRs have made it even easier for administrators, payers, reviewers, and government agencies to add required fields to the EHR so that they can track data, overloading the nurse with documentation requirements.

"Many of the documentation requirements that are considered excessive by nurses were put into EHRs to meet Joint Commission standards for core measures (eg, stroke, acute myocardial infarction, and venous thromboembolism) and to meet quality care measures for CMS [Centers for Medicare & Medicaid Services]. As CMS reimbursement shifts from volume to outcomes-based reimbursement (value-based purchasing programs), nurses can expect to see more required documentation," explains Angie Kohle-Ersher.

Willa Fields acknowledges that the burden of nursing documentation, whether on paper or computer, has increased over time. She disagrees, however, that such requirements are unrelated to patient care, and believes that nurses need to broaden their view of what they do, reminding them of the tremendous value of their documentation to all patient care. "Patient care is more than what we provide to individual patients," says Fields. "The information that nurses document can be analyzed to identify opportunities for improvement both for individual patients and the population at large."

Luann Whittenburg believes that we need to bring the nursing process back to nursing documentation. Current EHRs, she says, have disconnected the nursing assessment from the nursing process that supports nursing care decisions: nursing diagnoses, planning, interventions, and outcomes.[19] "The future for the EHR involves expanding the capture of coded nursing data using a nursing language that follows the nursing process for patient care. Nurses can then begin to tell a cohesive and accurate electronic patient story in an EHR." At Medicomp, Whittenburg is currently testing a system that will accomplish this by providing nurses with a single note space that is customizable for each organization and works with other components in a nursing documentation tool.


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