Simplifying documentation provides nurses more time at the bedside
Nursing documentation is an overcomplicated process. Although many Joint Commission standards require documentation, hospitals tend to write policies with which they cannot comply.
In HCPro’s April 30 audio conference, “Simplifying Nursing Documentation: Meet Regulatory Requirements and Reduce the Burden on Your Staff,” Bud Pate, REHS, vice president for content and development at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, and Lisa Eddy, RN, CPHQ, senior consultant at Greeley, discussed how hospitals over-burden themselves concerning documentation. “Folks across the country are struggling with how much time nurses are spending at the chart or computer, rather than at the bedside, and we think this is one approach to addressing that, while at the same time achieving compliance,” said Pate.
Nursing documentation has become increasingly complicated. There are numerous Joint Commission standards that require nursing documentation and can pose challenges to an organization (see p. 10). The following problematic areas were discussed during the audio conference.
The initial assessment
Nurses are required to complete an initial assessment within 24 hours of patient admission. However, hospitals define what information is collected in various settings and for various patients. When indicated, the initial assessment should include a physical assessment, psychosocial assessment, nutrition and hydration status, and functional status.
Hospitals often fail by requiring the nursing staff to collect too much information in the initial assessment, much of which has little bearing on the patient’s care, said Eddy.
“We’re encouraging you to consider that less really is more and that you require staff only to collect information that makes a real difference in how they plan and provide care,” she said
Nutritional and functional screening
Nutritional and functional assessments also must be performed within 24 hours of admission. Nursing staff often fall out of compliance because screening and accompanying documentation do not always work to identify patients with a need for dietary and rehabilitation services, said Eddy.
She suggests following the natural process of what often occurs in the dietary department with a diagnosis, procedure, diet order, and diet tech review, because nursing referrals are not technically required.
“Nutritional services has nutritional screening,” Eddy said. “They identify the patients on their own, and the same concept holds true for functional screening. Evaluate the processes and disciplines that already have these processes in place and ask yourself, ‘Does nursing really have to perform this function, or would it be better performed by the services that provide that type of care to the patient?’ ”
Pain documentation often falls out of compliance because hospitals require documented reassessments of pain at intervals that are not realistic and not required by regulation, said Eddy. Hospitals are often cited for not upholding their own stringent requirements. Additionally, nurses frequently do not have time to document patients’ pain levels as often as required and forget to do it later, regardless of whether they are assessing patients’ pain—and they usually are.
Eddy suggests revising your policy to reflect actual practice and educating physicians and nurses about pain management. Requiring real-time documentation may invite failure. “Why not write a policy that says, ‘The patient’s pain level will be reassessed in accordance with the intervention provided but not documented until the end of the nurses’ shift,’ and then you map your shift assessment and care planning evaluation piece to reflect that,” she said.
Patient Safety Monitor (Briefings on Patient Safety), September 2010, HCPro, Inc.
Challenging nursing standards
a. PC.01.02.01, element of performance (EP) 4 (hospital defines required information gathered in initial assessments: nutritional status, functional status, psychological/social)
b. PC.01.02.03, EP 6 (initial nursing assessment within 24 hours)
c. PC.01.02.03, EPs 7 and 8 (nutritional/functional screening)
a. PC.01.02.03, EP 3 (reassessments based on plan of care)
3. Care planning
a. PC.01.02.05, EP 5 (nursing care based on initial assessment)
b. PC.01.03.01, EP 1 (plan of care based on the assessed needs of the patient)
c. PC.01.03.01, EP 5 (plan of care based on the goals, time frames, settings, and services required to meet goals)
d. PC.01.03.01, EPs 22 and 23 (progress toward goals is evaluated/plan of care revised accordingly)
a. PC.01.02.07, EPs 1 and 3 (initial pain assessment and reassessments)
a. PC.03.05.01, EPs 3–5 (less restrictive measures, discontinuation)
b. PC.03.05.05, EPs 1 and 6 (initial and renewal orders for restraint)
c. PC.03.05.07, EP 1 (patient monitoring)
d. PC.03.05.15, EP 1 (documentation)
e. PC.03.05.03, EP 2 (restraint included in plan of care)
a. PC.02.03.01, EP 1 (learning needs assessment)
i. EP 4 (education based on assessed needs)
ii. EP 5 (coordination with other disciplines)
iii. EP 10 (based on assessed needs, education as appropriate)
b. PC.02.03.01, EP 27 (communication of safety concerns)
c. NPSG.07.03.01, EP 3 (multidrug-resistant organisms patient/family education)
d. NPSG.07.04.01, EP 2 (central line infection prevention patient/family education)
e. NPSG.07.05.01, EP 2 (surgical site infection prevention patient/family education)
7. Medication reconciliation (existing standards 08.01.01–08.04.01)
a. NPSG.03.07.01, EPs 1–5 (Joint Commission investigating alternatives; not scored until July 2011 at the earliest)
8. Coordination of care
a. PC.02.02.01, EPs 2 and 3 (handoff communication and care coordination)
Source: “Simplifying Nursing Documentation: Meet Regulatory Requirements and Reduce the Burden on Your Staff.”