3 Practice Breakdown
Clearly Communicating Patient Data and Clinical Assessments
ISSUES IN NURSING DOCUMENTATION
Currently patient care documentation is found in a variety of forms and formats, handwritten and computerized. Written documentation systems have been developed to assist clinicians to produce accurate and comprehensive documentation. Examples include the following: (a) problem-intervention-evaluation charting (PIE); (b) subjective-objective-assessment-plan charting (SOAP); (c) problem-oriented medical record charting (POMR); and (d) charting by exception formats, outcome-based charting; and critical pathways (Meiner, 1999). Checklists for exception charting to address the time restraints have been implemented as documentation requirements for regulatory compliance increase. At times, nurses shortcut documentation because of time constraints or limitations of these forms at the expense of complete charting.
DOCUMENTATION OF THE FUTURE
1. Design of documentation systems that more closely reflect actual work processes and patient throughput, supporting clinician assessments and work organization
2. Integration of physician order entry, medication administration, and clinician documentation systems
3. Inclusion of a framework that encompasses nursing knowledge functions as a cognitive map for clinicians (nurses handle large amounts of data and often experience overload and stress; also provides professional support in making complex clinical decisions) and increases efficiency (von Krogh et al., 2005)
4. Integration of standards-based organizing frameworks such as Nursing Interventions (NIC), Nursing Outcomes (NOC), and North American Nursing Diagnosis Association (NANDA)
5. Use of a complex and comprehensive database for patient and nursing research
6. Inclusion of alerts, popups, and protocols to guide caregivers in both care processes and documentation
1. Elimination of illegibility
3. Improved response time to patient requests
4. Simultaneous, real-time access to up-to-date patient data for multiple clinicians
5. Improved documentation completeness
6. Increased compliance with regulatory requirements (e.g., assessments for pain level, skin integrity, and fall risk)
The importance of documentation becomes apparent following reviews of incidents in which a patient has been affected negatively. Not surprisingly, documentation is rarely the primary error. The down side of the extensive requirements for documentation in today’s complex hospitals is that the nurse can spend from 13% to 28% of his or her time in patient care documentation, and this reduction in the nurses’ availability to provide direct patient care has been shown to diminish patient safety (Korst et al., 2003; Pabst et al., 1996; Page, 2004).