Bringing Purpose and Meaning Back to Nursing, One (Less) Click at a Time

Documentation burden is a complex issue consisting of many people, processes, policies/procedures, and external regulations. Documentation burden can result in a loss of documentation meaningfulness and efficiency, increased time away from patient care, and reduced joy in practice. After the initial rollout of the electronic health record (EHR) at this organization in 2007, there had been no major documentation workflow enhancements. This resulted in a variety of challenges, including increased documentation requirements and burden, and major variations compared to the EHR vendor’s recommendations. Furthermore, the differences in physical assessment documentation resulted in decreased standardization and communication between departments and decreased satisfaction.
To reduce documentation burden and improve efficiency, standardization, and nursing satisfaction, “within defined limits” (WDL) was implemented. WDL documentation supports reducing documentation burden by providing a consistent, standard process for efficiently recording comprehensive physical assessments against a defined parameter. WDL defines baseline assessment criterion that aligns with the ANA standard of providing clear, accurate, and accessible documentation of the patient’s assessments, responses, and outcomes. The project scope included standardizing the nurses’ physical assessment documentation in all departments, except ambulatory care clinics. This project was successfully implemented in just 16-weeks!

The project was successful due to the multidisciplinary stakeholders, including key expert clinical nurses serving as decision-makers, workflow experts, and department training leads. In addition, nursing informatics partnered with the EHR training team to prepare a teaser video announcing the upcoming enhancement. Official training for this project included tip sheets, recorded demos, and in-person rounding to demonstrate WDL. The new workflows were also introduced and communicated through presentations at leadership, education, and clinical stakeholder meetings.
The reduction of documentation burden and increased nurse satisfaction was felt within hours of go-live. Nurses shared that WDL saved them so much time that they could “actually eat lunch today” and “spend time with patients and their families.” Data was collected through satisfaction surveys and EHR reports to evaluate the outcomes of WDL. The implementation of WDL decreased the standard physical assessment flowsheet documentation fields by 78%, decreased acute care nurses’ documentation time by 30 minutes per shift, and increased nurses’ satisfaction from 24% to 75%! WDL helped bring purpose and meaning back to nursing, one less click at a time!