Abstract: Ideal nursing documentation is a reflection of nursing professional practice and the use of the nursing process in care. Along with being part of the legal medical record, it helps to meet regulatory and quality reporting requirements, outlines the plan for the patient, and contributes to the coordination of care.

However, many clinicians are finding that the value of nursing documentation has become lost with the complexities of the electronic health record. Providers report that they do not see or read nursing documentation that is buried in flowsheets. Nurses are observed or report copying previous documentation. Plans of care are hidden in flowsheet documentation, checklists are buried in notes, and redundancies abound.

The Informatics team at Hennepin County Medical Center (HCMC) will tell of their journey through a major inpatient nursing documentation overhaul. Taking an innovative approach to the documentation of the nursing head to toe assessment, they moved the shift assessment out of flowsheets and into a point-and-click system in the electronic health record that automatically creates a note. With a focus on nursing efficiency and telling the patient story, they mapped the elements of nursing documentation to the nursing process so that the assessment informs the care plan, which automates the flowsheet intervention documentation.

Objectives

a. Describe the factors that contribute to the need to streamline inpatient nursing documentation.

b. Identify how data and analytics can support the design and content creation for nursing documentation.

c. Understand the strategies for educating and implementing a large-scale documentation change that includes embedding the nursing process in telling the story of the patient.