Identification of the Problem

                In the ever-changing world of technology and nursing informatics, there are always advantages: having barcode administration for safe medication administration, wireless paging to reach healthcare providers, and also telehealth, for people who may not have the leisure of seeing a provider when needed. But with every advantage, there are also disadvantages. When a patient is first admitted, a nurse has to ask the typical questions about the past medical history, the same, repetitive questions over and over again. On some of the patients, frustration is expressed through a “sigh” or a comment about asking why the questions are being asked again. Within one admission process, from the Emergency Department until the patient gets transferred to the floor, the same questions are asked over and over again. In my organization, redundant documentation forms were found in a patient’s chart so much that the nurses had to sort the documents to the most recent date to find updated information on the patient. So how can one be able to consolidate information to where nurses don’t have to continually document and ask repetitive questions whilst a patient is awaiting to seek treatment without being annoyed? As Cowden and Johnson state, “Forms capturing redundant data can lead to duplicate documentation. This can be a source of patient and staff frustration, as well as data errors” (Cowden & Johnson, 2014, p.93)  

Proposed Solutions

At my organization, we use Cerna. With every shift, we have to document the interdisciplinary plan of care in each field. We then have to document the Morse scale and the other organizational forms. Every shift is required to document the same form, but the problem is, the forms don’t carry over. One nurse’s from may be different from the previous shift’s nurse. So how would you know which data is accurate? I would suggest using the same form for the same patient throughout the patient’s stay, but with updates, and why the nurse had to change or update the status. For example, when a patient is first admitted, the form will ask, keep patient at baseline, you have to checkmark it. Next to that checkmark, we have to document that we initiated that status. The next nurse has to checkmark the same box, then update the status to progressing, changing it from initiated. It goes on and on this way, which is a lot of clicking. Having six to seven patients at my hospital, with 50 boxes to checkmark and to update, it takes quite a bit of time, time that could be spent at the bedside, instead of in front of a computer.

                An observational comparative study was performed among eight clinics along with three mental health centers to figure out a workaround to the challenges of duplicate data-entry, double documentation, and syncing of information from one provider to another. To overcome the challenge of double documentation and duplicate date entry, all providers should be see the same screen, with a certain area for each provider to provide their input. For example, a patient can have multiple consultations, one from cardiology, and the other from nephrology. It would be nice to see all providers write their notes and updates on a specified section designated for their specialty n the patient’s chart. At my organization, there is a form that takes all the patient data and copies it and the doctor would write at the bottom of the form what he recommends. The next provider that sees the patient would copy and paste everything from the previous doctor and write his input at the bottom. In every progress note, the information is the same, redundant, and unnecessary. The patient’s data should be at the very top, a section should be designated for each specialty, so nurses won’t have to waste time to sort through the old and new information (Cifuentes et al., 2015).

                Another solution for duplicate and redundant documentation is to have customized templates within the electronic health record and standardizing care plans. A survey was completed in 2013 with 116 registered nurses with experience to test out standardized care plans, the results? The nurses reported that not only did it facilitate their work, the documentation resulted in less time-consuming, less redundant information. The nurses also stated that it worked well as a checklist to ensure quality of care (Jakobsson & Wann-Hansson, 2013).

Benefits to Nursing

                Not having redundant information in a patient’s chart not only can save nurses so much time to sort through irrelevant information, it can create more time for the patient. For example, a patient that has been hospitalized for 30 days, I wouldn’t want to know everything that happened to the patient from day two to the twentieth day. I would like to know why the patient was admitted to why the patient is still here, and what are we doing about it. Not only are we saving time for ourselves when we sort all the unneeded information, we create more time for patient care. Laura Stokowski emphasize that electronic health records have increased an additional three hours to a nurse’s shift on top of the twelve-hour shift that they already are required. She explains that the extra time is due to the “endless logging in and out, paging through unnecessary screens, duplicate entries, finding where the information is, and figuring out where to chart” (Stokowski, 2013, para.11). Redundant and double documentation adds to the many time constraints of financial budgeting and working way longer hours on top of a nurse’s shift. Reducing this challenge will add more time for nurses to perform other necessary tasks for the patient that are more important than sitting in front of a computer to chart.

Benefits to Patient

                Time, it is the most important factor when eliminating redundant documentation. Time is what will help the patient, the provider, and the nurse. If the nurse can spend more time with the patient, better care can be achieved, communication can be more efficient, and nurses can better provide the patient with the needs that they require with the additional time provided. Better care can be achieved by being able to look through the chart and find what they need, instead of sorting through all the information from weeks ago. The nurse can also provide better care by updating the patient’s chart from the previous nurse’s assessment, so the assessments aren’t too contradictory. The nurse can then tell the oncoming nurse what has changed, eliminating discrepancies. As patient care becomes more complex, more situations arise where the patient needs more nurses by the bedside, to monitor status and to pick up on instant deviations from the baseline. This is why it is crucial for nurses and healthcare providers to spend more time with patients instead of sorting through documents and charting on top of the documentation. This will improve not only time, but safety for the patient, as well. If a patient’s chart is documented in a single location, with updates in the areas specified, then it will become more consistent. Inconsistencies and redundancy can lead to errors, inaccurate information, and waste critical time with our patients.

References

Cifuentes, M., Davis, M., Fernald, D., Gunn, R., Dickinson, P., & Cohen, D. J. (2015). Electronic Health Record Challenges, Workarounds, and Solutions Observed in Practices Integrating Behavioral Health and Primary Care. The Journal of the American Board of Family Medicine, 28(1), S63-S72. doi:10.3122/jabfm.2015.s1.150133

Jakobsson, J., & Wann-Hansson, C. (2013). Nurses' perceptions of working according to standardized care plans: a questionnaire study. Scandinavian Journal of Caring Sciences, 27(4), 945-952. doi:10.1111/scs.12009

Stokowski, L. (2013, September 12). Electronic nursing documentation: charting new territory. Retrieved from www.ccsettings.com/blog-posts/electronic-nursing-documentation-charting-new-territory/