We Have So Much Clinical Documentation. The Question Is, Are We Better For It? Streamline Nursing Documentation Now To Improve Outcomes Later.

Talking about nursing documentation will age me, but here it goes. Those of you who have done home health and hospice for a long time will remember when documentation was much simpler. While the introduction of the EMR has been amazing for portability, I question how “good” it is for the patient and clinicians. Let’s take a look back to see the transition from not enough to potentially too much in terms of nursing documentation.

Remember The Flow Sheet?

Ok, here is where the age thing comes into play. When I first started as a nurse in the home health and hospice field, we had flow sheets. Remember those? Vitals, each body system, interventions specific to the patient, time in and out, signatures, and the clinical note on the back. The nurse who was seeing that patient had a copy of the 485 and could easily see what was happening with that patient by reviewing the beloved clinical notes. The narrative note was where you could expand on that wound care, talk about teaching and the plan for your next visit. The abnormal findings were easily and clearly presented. Your communication with the doctor was right there. It was easy to follow.

Now, let’s fast forward to the EMR. Suddenly, the nursing visit that was the equivalent of a page or page and a half has turned into 4-5 pages of documentation. There are so many options as to where things are documented that someone reviewing a chart could find communication with the doctor in the individual body system, a narrative note, or in a communications tab. Or, it is documented in all 3?

The 485 is written with so many interventions because care plans are already in your EMR based upon diagnosis. If we use template care plans, then how are we making them patient specific when customization doesn’t happen? In working with agencies throughout the United States, this is a consistent finding in my experience. So, when I look at 2 patients who are very different side-by-side, they look the exact same on paper. Nurses spend more time documenting, patients get lost in the mix, and the outcomes aren’t better for all the available data. So, how do we change this?

So, How Do You Streamline Nursing Documentation?

Let’s look at this step-by-step to improve efficiency, specificity of care, and outcome-based care plans. Here are 4 things to consider:

1. Narrow Your Goals/Focus: The reality is that we have a short amount of time with this patient in the home. Most patients aren’t being held past the first thirty days and if so, they are still discharged by day 60. Ask yourself, what are you in this home to accomplish? How many interventions are longer term goals that aren’t really relevant to this exacerbation of illness? What is the patient’s goal? Instead of having 10-15 goals for the patient, aren’t there more like 3-5 very relevant ones? Focus on these.
2. Assessment Templates: Many agencies set up the EMR with the majority of items activated. What we tend to see is a lot of extra time going through check boxes that are not relevant to that patient. Nurses need taught to activate more when it is relevant and deactivate when it is not. Do they have that right within your EMR? You need to keep the necessities in the template and allow the clinician to add things that are relevant on patient admission and as problems arise.
3. Interventions: This is where we see the never-ending 485. If we see a 4 page 485 on a patient you expect to discharge in 3 weeks, your care plan needs some work. Within a template care plan, so many of the interventions overlap. Streamline the goals and interventions to match the specific issues of the patient at that time.
4. Utilize A Clinical Note: With the massive amount of data available on patients, nurses aren’t able to read and scroll through every visit previously made. Make it very easy for the next clinician to know exactly what has happened. The clinical note allows the nurse to easily scan through multiple visits simply and chronologically. The nurse can deep dive into specific assessments and visits for more data. Agencies that eliminated clinical notes in day-to-day practice make it hard for nurses in the field to easily access data.

Need Help Making It Happen?

Our goal with agencies is to help them with solutions that make sense. We don’t need to complicate the process more than it already is, but develop solutions that allow us as agencies to work smarter. This means changes focused on quality efficient care. Call us today at 419-790-4454 or contact us online to see how Peek Consulting can help!