Report: Challenges and Opportunities in Documentation of the Nursing Care of Patients

[rnformatics]

An interesting bit of news that came across the CARING list:

The Maryland Workforce Commission is pleased to announce the release of a report titled:

Challenges and Opportunities in Documentation of the Nursing Care of Patients: A Report of the Maryland Nursing Workforce Commission, Documentation Work Group

The report is authored by: Brian Gugerty, DNS, RN, Michael J. Maranda, PhD, Mary Beachley, MS, RN, CNAA, Victoria B. Navarro, MAS, MSN, RN, Susan Newbold, PhD, RN-BC, FAAN, FHIMSS, Wahnita Hawk, LPN, Judy Karp, RNC, OCN, Maria Koszalka EdD, RN, Steven Morrison, JD, Stephanie S. Poe, MScN, RN and Donna Wilhelm, RNC.

The report includes the results of a survey of 933 Maryland nurses and recommendations of the Work Group.

You may access the report via http://www.mbon.org/commission2/documenation_challenges.pdf

I think that this quote sums up the article quite well:

The data from this survey lends support for a mixed ‘report card’ for electronic documentation. Nurses who used electronic documentation reported increased:

• Redundant documentation
• Time spent on documentation

But, at the same time, reported increased

• Completeness of documentation
• Quality of documentation.

The majority of nurses using electronic documentation had input into the development or use of the systems in their workplace, but there was substantial sentiment that the systems were poorly designed and not integrated with the many other systems in use.

The authors also go on to propose that by streamlining nursing documentation such we could decrease the cost of providing nursing care while simultaneously increasing the amount of direct patient care time.

The article is well worth a read - especially by anyone involved with clinical documentation.