nursing journal article on documentation

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BALANCING DOCUMENTATION AND DIRECT PATIENT CARE ACTIVITIES: A STUDY OF A MATURE ELECTRONIC HEALTH RECORD SYSTEM

US hospitals now fully embrace electronic documentation systems as a way to reduce medical errors and improve patient safety outcomes. Whether spending time on electronic documentation detracts from the time available for direct patient care, however, is still unresolved. There is no knowledge on the permanent effects of documenting electronically and whether it takes away significant time from patient care when the healthcare information system is mature. To understand the time spent on documentation, direct patient care tasks, and other clinical tasks in a mature information system, we conducted an observational and interview study in a midwestern academic hospital. The hospital implemented an electronic medical record system 11 years ago. We observed 22 health care workers across intensive care units, inpatient floors, and an outpatient clinic in the hospital. Results show that healthcare workers spend more time on documentation activities compared to patient care activities. Clinical roles have no influence on the time spent on documentation. This paper describes results on the time spent between documentation and patient care tasks, and discusses implications for future practice.

Relevance to Industry

The study applies to healthcare industry that faces immense challenges in balancing documentation activities and patient care activities.

1. Introduction

1.1. medical errors and electronic documentation systems.

Medical errors continue to be a prevalent problem in the US. In its landmark “To Err is Human” report released in 1999, the Institute of Medicine first highlighted the urgency to address mortality due to medical errors in hospitals ( Donaldson, Corrigan, Kohn, & others, 2000 ). Since then, the medical error problem has only grown. A recent study by Makary & Daniel (2016) suggests that over 250,000 deaths occur every year in the US because of medical errors. This mortality rate due to medical errors is comparable in magnitude to deaths from chronic lower respiratory illnesses, the third biggest cause of mortality in the US. It is next only to cardiovascular disease and cancer, highlighting the seriousness of the problem. Reducing medical errors and improving patient safety outcomes continue to challenge hospitals in the US.

Researchers have been examining how best to reduce medical errors and improve patient safety and healthcare outcomes. Specifically, studies have examined the impact electronic health records (EHR) system designs have on healthcare quality and healthcare outcomes ( Jones et al., 2010 ; Jarvis et al., 2013 ; Linder et al., 2007 ; Jamal, McKenzie and Clark, 2009 ). In the most recent, extensive meta-analytic review of the benefits of EHR in reducing medical errors, Campanella et al. (2015) conclude that effective implementation of electronic documentation systems can not only reduce medication errors, but can also significantly improve healthcare quality.

Based on the potential for EHR to positively impact patient safety and healthcare quality, US hospitals have now fully embraced electronic documentation systems. That many hospitals in the US have now transitioned from paper-based documentation to electronic documentation illustrates this adoption. The Office of the National Coordinator for Health Information Technology reported that, as of 2016, 95% of critical care hospitals had adopted electronic health records (EHR) ( “Health IT Quick Stats,” 2018 ). Financial incentives to go electronic have also sped up the transition. The Health Information Technology for Economic and Clinical Health Act of 2009 first incentivized US hospitals to adopt and implement electronic health records ( Kruse, Kristof, Jones, Mitchell, & Martinez, 2016 ). Since then, US federal agencies have invested nearly $20 billion dollars in the transition effort ( Grinspan, Banerjee, Kaushal, & Kern, 2013 ). These efforts have now resulted in electronic documentation systems becoming ubiquitous in clinical practice in US hospitals. Healthcare workers now routinely use electronic documentation systems in their clinical practice to achieve patient safety outcomes.

1.2. Problems with electronic documentation: the healthcare practitioner’s perspectives

Even though the mainstream hospitals and clinics in the US have integrated electronic documentation systems in their clinical practices, healthcare practitioners continue to doubt the effectiveness of these systems for patient care. Their doubts stem from three main concerns. First, they report that electronic documentation activities take valuable time away from patient care. There is merit to their concern, as studies show that healthcare workers spend up to half their working day on documentation, and that physicians and residents consider the time they spend on electronic documentation to be high ( Christino et al., 2013 ; Oxentenko, West, Popkave, Weinberger, & Kolars, 2010 ). Second, healthcare workers struggle to balance documentation and patient care tasks and feel that the documentation burden compromises their patient care. Surveys show that physician residents feel rushed when interacting with patients because they feel pressured to complete their documentation tasks, particularly when facing restricted duty hours which already imposes a time constraint on them ( Christino et al., 2013 ). Third, the utility and value of the electronic documentation concerns them, given the time they spend creating the documentation. Studies show that providers do not fully use electronic notes, and that they read only one-sixth of such notes ( Hripcsak, Vawdrey, Fred, & Bostwick, 2011 ). In addition, research shows that the utility for note categories such as daily progress notes drops off with time ( Hripcsak et al., 2011 ).

While electronic documentation has enabled quick and easy creation and storage of vast amounts of patient information, healthcare workers continue to debate the utility and the value of the information they create using electronic systems. Their main concern is whether the time they need to allocate for electronic documentation will detract from the time they must spend on direct patient care.

1.3. Electronic documentation time versus patient care time: what we know

Studies have specifically examined this issue – that is, whether electronic documentation tasks take a disproportionate length of time compared to the time healthcare workers spend on patient care. But these studies are inconclusive and report mixed results. Some studies report a decrease in patient care time, with no significant changes in documentation time when transitioning from paper-based to electronic. For example, Pizziferri et al., (2005) , in a study of outpatient clinics, reported an overall decrease of half a minute in patient care time with the new electronic system, but with no significant changes in documentation time from a paper-based system to electronic system. Other studies report that healthcare workers spend an equal length of time on documentation and patient care tasks. Tai-Seale et al., (2017) in a study evaluating how primary care physicians used their time, analyzed time stamp data from electronic health records. They found that physicians spent about 3.08 hours a day on face-to-face patient visits, and about an equal length of time (3.17 hours a day) on electronic documentation. The work sampling study by Ammenwerth & Spötl, (2009) reported that 27.5% of the activities of physicians and residents related to patient care, and 26.6% related to documentation activities, indicating that the frequency of patient care activities was about the same as the frequency of documentation activities. Many studies report an increase in documentation time and a decrease in patient care time with electronic systems. In a pre-post study of the impact of electronic medical records on nurse documentation time, Hakes & Whittington (2008) found that the proportion of time spent on documentation and indirect care increased, while the time spent on patient care decreased. In a more recent pre-post comparison when implementing a structured and standardized EHR in two health centers, one with paper-based system and one with a legacy EHR, Joukes, Abu-Hanna, Cornet, & de Keizer (2018) found an increase in documentation time in the center using paper-based systems, and a decrease in patient care time in the center using a legacy system.

We can conclude from our review of published studies that the question whether spending time on electronic documentation detracts from the time available for direct patient care is still unresolved. Our review also shows that the studies have a striking similarity - researchers conducted these studies close to the time when the hospital in the respective study first implemented an electronic documentation system. The electronic documentation system would have been new to the healthcare workers and would not have been mature and stable enough to detect and capture nuanced time differences in documentation and patient care activities.

1.4. Evaluating electronic documentation burden: the case for examining mature EHRs

When the healthcare information system is mature, however, and has been operational for an extended length of time, one can expect to see the more permanent effects of documenting electronically and evaluate whether it takes away significant time from patient care. The assumption is that healthcare workers would have learnt to use the electronic system with time, and that any observed documentation and patient care times would truly show the time spent on these respective activities.

There is support in the literature for this idea of examining a mature system to evaluate the effectiveness of electronic documentation systems. A systematic review by Poissant (2005) shows that evaluations conducted soon after (only about a month) implementation of electronic documentation systems found either decreases in documentation time, or no change in times. In contrast, evaluations conducted after a longer duration (about a year) since implementation showed increases. A study by Pabst, Scherubel, & Minnick, (1996) evaluating an electronic health record only 3 months after implementation showed that nurses decreased their documentation time by one-third from 13.7% to 9.1%. Another study evaluating a computerized clinical documentation system 3 months after implementation ( Menke, Broner, Campbell, McKissick, & Edwards-Beckett, 2001 ) showed no change in the time spent on documentation or patient care. In contrast, Hakes & Whittington (2008) conducted their study a year after implementation; they found that documentation time increased in the year after implementation. A similar study by Overhage, Perkins, Tierney, & McDonald, (2001) evaluating an electronic healthcare information system combining physician order entry, documentation and billing in the year after implementation, showed a slight increase in the time for writing orders.

There are two reasons the observed documentation times can increase after implementation of an electronic system. One reason can be that healthcare workers try to use new and sophisticated functionality in the electronic documentation systems, and that they learn the system over time – the learning effect may reflect on increased documentation times. A second reason can be that IT support, active during the initial implementation, becomes inactive with time, requiring the healthcare workers to spend more time troubleshooting and discovering functionality ( Hakes & Whittington, 2008 ).

Hence, one can expect that the effects of implementing electronic documentation systems will show only after an extended time since implementation when the system has had the time to stabilize and mature.

1.5. Study goals

To understand the time spent on documentation, direct patient care tasks, and other clinical tasks in a mature information system, we conducted an observational and interview study in a midwestern academic healthcare system. The hospital first implemented their electronic medical record system 11 years ago. We observed 22 health care workers across intensive care units, inpatient floors, and an outpatient clinic to assess the balance between documentation and patient care tasks. This paper describes results on time spent between documentation and patient care tasks and discusses implications for future practice.

2. Materials and Methods

2.1. study design.

We used a purposive, typical case sampling strategy ( Creswell & Creswell, 2017 ) to recruit the healthcare workers taking part in our study. A purposive sample is one in which the researcher selects participants based on distinctive characteristics they bring to the study – for our study, the purpose was to investigate the work activities of healthcare workers in a hospital so we could quantify how much time they spend on various documentation and patient care activities; hence, we purposively sampled healthcare workers who are physicians, nurses, residents in healthcare units (i.e., intensive care units, inpatient units, and outpatient clinics) in an academic hospital. A typical case sampling strategy strives to select participants typical of the work domain, and not deviant or extreme from what researchers consider normal for that work domain. In our study, we chose as study subjects healthcare workers who would interact with patients, when patients undergo care during their hospital stay. If we had, for example, only considered healthcare workers who cared for patients whose vitals had worsened, that would have been an atypical or an extreme case sample.

We used an observational approach to collect data about the work activity of healthcare workers, and followed it up with clarification interviews with them. With the observational approach, shadowing the healthcare workers throughout their normal workday was our strategy. Our shadowing sessions involved documenting all activities of the healthcare workers and the corresponding clock times they spent on the activities. An observational approach was suitable for our study because it gave us an unstructured, dynamic narrative of healthcare worker activities during a typical work shift. The data was unstructured because we did not pre-define any categories into which the raw observed data would go. Our data was dynamic because we tracked the work activity over time.

Our observational approach, a variant of the work sampling technique ( Freivalds & Niebel, 2013 ), helped us observe one healthcare worker for one work shift (either 8 or 12 hours), and document all their activities during that shift. Hence, we sampled a small portion of their activities from their complete weekly schedule, when they see many patients as part of their work within a scheduled healthcare team that takes turns seeing patients.

During our shadowing, we did not interrupt the healthcare worker’s clinical workflow to ask them questions we may have had regarding their activities. A separate interview session followed the shadowing so we could ask for clarification. The clarification interviews lasted between 15 to 30 minutes, for an average duration of 25 minutes with each healthcare worker. We used Transana™ for the transcription of the interview data. The design we chose for our study captures the dynamic nature of a healthcare workers’ day, and helps identify the time, duration, and nature of activities they engage in throughout their typical workday.

2.2. Setting and Participants

The study was conducted in a large, trauma care academic hospital in the Midwest in the following hospital settings: (1) medical, cardiovascular, and surgical intensive care units (ICU); (2) general medicine, adult surgical specialty services, medical surgical cardiology and respiratory specialty care inpatient floors; and (3) general medicine outpatient clinic. The study setting is a 729-bed hospital and academic medical center with over 30,000 admissions in 2011. The hospital has 155 intensive care beds, 718 inpatient beds, and 561 acute care beds. The hospital implemented an electronic medical record system eleven years ago. The hospital has since attained stage 7 in HIMSS analytic scale indicating progress in electronic medical record implementation. HIMSS considers stage 7 as the most advanced patient record system.

Our study gathered data from 22 healthcare workers, composed of 8 physicians, 12 nurses and 2 residents. As previously mentioned, this sample represents the healthcare workers who take part in a typical patient’s hospital stay in the intensive care units, inpatient floors and outpatient clinics.

After approval from our Institutional Review Board, we recruited participants through posters displayed in the clinical units, and presentations about the project during huddles, morning rounds and other team meetings conducted in the clinical units. The posters and presentations supplied information on the project and described time commitment requirements for taking part in the study. Participants interested in volunteering for the study contacted the second author to express their interest to participate. Based on their availability, we then scheduled data collection. We waived participant documentation of consent as the written record would link participant identifiers to the data. The researchers compensated each participant with a $25 gift card for taking part in the shadowing session, and $25 gift card for participating in the follow-up clarification interview. We specified no other inclusion or exclusion criteria, except that they had to be a healthcare worker in one of the hospital units we had selected.

2.3. Experimental Procedure

In each medical unit we listed in section 2.2., we observed workers administering care to their patients, and documenting their care, during the following major care process events: (1) day-to-day care in the ICU (2) day-to-day patient care in the floor units and (3) during patients’ first outpatient visit.

We began the shadowing session at the start of their shift and followed them everywhere. Our physical location was proximal to them at all times (that is, at a comfortable distance from where we could clearly see and classify their activities such as work with the computer screens when writing notes). The only times we did not shadow them was during their breaks, and when they went into patient rooms. Each shadowing session lasted either 8 or 12 hours, depending upon their shift times. Most participants we observed had a 12-hour workday beginning at 7 am and ending at 7 pm. A few of our participants worked in shorter shifts of 8 hours. We followed one healthcare worker on one day and collected the entire study data on 22 separate days. When the healthcare worker entered the patient’s room, we recorded this activity in our shadowing notes and categorized it as a patient care activity. We did not speak to the healthcare workers during the shadowing session to get any clarifications (unless first prompted by the healthcare worker), so as not to disrupt their clinical activities. We observed their entire note-taking and documentation processes, handoffs, discharge sign-outs, discharge planning and coordination activities, and their activities during patient admissions and transfers (including activities during interdisciplinary meetings for nurse navigators).

We wrote notes about healthcare workers’ activities, the clock time they spent on each activity, the tools and technologies they used, and all instances of communication. For example, if the healthcare worker went inside a patient’s room to perform a procedure, we used our watch to note the time they went in, the time they came out, and assigned a broad code to categorize their activity during that time (in this case, categorized as patient care). Once they came out, if they used an electronic medical record system to document their care, we categorized this as documentation activity, and noted the tools and technologies they used for the documentation activity, and the start and end times for the activity. Sometimes, when an activity extended for a longer duration (e.g., if the healthcare workers were in a team room all afternoon using the electronic medical record for documentation), we still noted the beginning and ending times of the activity, but also added all the clock times when they were interrupted for any other activity. All the clock times we recorded, with details of how and what they were documenting, also helped us to ensure that they were engaging in documentation activity for that entire duration. We could also clearly demarcate the times for any additional overlapping activities such as communication over phone that occurred during a documentation activity.

Each shadowing note contained a detailed account of all the activities that a healthcare worker did with timestamps of when they occurred. Consider the two notes below about one participant, made at two different clock times in sequence, and reproduced verbatim:

7:00 am: The participant is doing the handoff report when beginning their shift. They use a printed sheet and the electronic system during handoff. [need to find out whether the printed sheet comes from the ES] There are some notes on the sheet. There are two different handoffs happening – that is handing off information and patients from/to 2 different nurses in the same pod. 7:20 am: The participant tells me they will give medications to the patient, do assessments and then charting. They are taking the COW computer with them for charting. They are adding their name to the list of patients for today in the electronic system.

From the note made at 7:00 am, we can see that “patient handoff” is the major coordination event. The printed sheet and the electronic system are the tools and the technology used for this activity. The text within [ ] indicates follow-up questions for the clarification interview. The note from 7:20 am shows an example of when participants voluntarily provided information before they performed major activities, especially when the activity was inside the patient’s room.

Each shadowing note included many such segments from observations made throughout the work shift. At the end of their workday, we conducted brief follow-up interviews lasting about 25 minutes to seek clarifications about questions we had when we shadowed them. The second author, who has a background in Industrial Engineering, and extensive training on qualitative field-based healthcare observations in major US hospitals and has worked for more than ten years with several teams of physician and nurse researchers, conducted all the shadowing and clarification interview sessions.

The researcher wrote all the observations in a notebook using a LiveScribe digital pen. The data obtained from the shadowing was transcribed from the digital handwritten notes to text form, both using the inbuilt functionality in the LiveScribe notebook, and through manual transcription. We checked all data for accuracy manually by comparing the original handwritten notes with the transcribed text. The first author aided in transcribing the notes from the shadowing sessions.

In summary, we generated the following items from our data collection effort:

• Data from either 8 or 12 hour shifts of shadowing on each of the 22 study participants on 22 separate days; the data was in the form of written notes, and audio-recorded clarification interviews.
• Transcripts from these shadowing sessions and clarification interviews.

2.4. Data Analysis

We analyzed the shadowing data from physicians, residents, and nurses to categorize their activities, and to identify how much time they spend on documentation activities compared to direct patient care, and other activities during their typical work shift.

First, we broadly classified the observed activities into direct patient care activities, documentation activities, communication and coordination activities, activities for team support, trainee education and patient education activities, and patient family coordination activities. These categories are typical of activities in any clinical unit and represent the major responsibilities of healthcare workers. In each shadowing note, we looked for descriptors of these activities. For example, “see the next patient” is a descriptor for a patient care activity. If we found a descriptor in the note, then the segment of the note with the corresponding timestamps was broadly classified into one of the major categories. Each segment could contain more than one descriptor and one category depending on what the healthcare workers did at that time instant. For example, the segments below are from a participant describing their activities. Example categories [ ] immediately followed by activities [ ] under those categories, and the descriptors { } that led us to classify under those categories are highlighted in the following note segments reproduced verbatim:

11:00 am: They go to {see the next patient} [Patient care] [patient assessment]. Before they see the next patient, they mark some information in their paper sheet that they have “seen” the patient. 11:05 am: They are out of the patient’s room. They are trying to {call someone} [Communication] [phone call]. They go back into the patient’s room, {asks for area code} [Patient care] [communicating with patients] and come back to call again. The participant is {speaking with a facility and asking them if the patient can come there; what facilities (medications, doctors, nurses}) that they have [Patient care] [discussing plans and results of patient care] and finally asking to speak to the doctor in that facility. 11:12 am: The participant finished talking to the doctor in that facility. The participant then goes to visit the patient, when the {nurse calls out with a question about a patient} [Communication] [discussing plans and results of patient care]. 11:13 am: The participant is {going in to see the patient} [Patient care] [communicating with patients] and update them about the phone call that they just had. 11:50 am: The participant is doing discharge for a patient so that they are not holding up the discharge – {they navigate different tabs in the electronic system for discharging the patient} [Documentation] [preparing discharge summary] – they are reconciling medications for discharge; the nurse stopped by to ask about a patient’s procedure; The {participant’s team} is working with them now [communication and coordination] [discussing plans and results of patient care]. The participant is on the ES. They are working on discharge orders.

Please see tables 1 , ​ ,2 2 and ​ and3 3 for the complete list of categories and activities under those categories we generated from the transcripts. Please note that our categorization was role specific because each participant had a specific role to fulfill in their work. Hence, not all activities were represented in every role. For example, the activity “education” typically involves residents and physicians for clinical training. It is also to be noted that an activity may not involve the same scope of work across the roles. For example, coordination for nurses might mean attending huddles, while coordination for physicians might mean discussing a patient with a consult.

The main categories of activities for nurses

The main categories of activities for physicians

The main categories of activities for Residents

Once all activities represented in the notes were categorized, for each healthcare worker, we mapped their work shift activity-time distributions by plotting their activities and the corresponding clock times when they performed the activities throughout their shift. With the categories and the corresponding activities available, for each participant, we calculated the category frequencies by counting the number of times each category occurred throughout the work shift. We then noted the beginning and ending times of that specific category and computed the activity duration. To ensure consistency in categorization and count analysis, the first author performed this analysis on a few participants first, which the second author reviewed for consistency and accuracy; the first author then computed the other frequencies and durations. Once we mapped the activities and times for each healthcare worker, we compared the frequencies and durations for nurses, residents, physicians. All data was normalized to 12 hours to facilitate comparisons between roles, because a majority of the healthcare workers we observed were on a 12-hour shift.

Finally, the average aggregated duration for documentation, and patient care activities were consolidated hour-by-hour for a work shift. With the categorized data, we conducted a paired t-test, a MANOVA, and univariate ANOVAs. A paired t-test was conducted to compare the overall times spent on documentation and patient care regardless of the clinical role of the healthcare provider. We also performed a MANOVA to understand and separate out the influence of different clinical roles on times spent on documentation and direct patient care activities. Univariate ANOVAs, conducted separately for each healthcare provider role, tested if their documentation times and direct patient care times differed significantly.

3.1. Time distributions between documentation, patient care and other activities

The main goal of the study was to determine whether healthcare workers spend a disproportionately large amount of time on documentation activities compared to direct patient care activities.

Table 4 shows the distribution of frequencies and time healthcare workers spent on different activities. Notably, on an average, documentation activities made up 40% of all activities across healthcare workers. Documentation also made up nearly 40% of the time spent by healthcare workers. Compared to documentation, direct patient care accounted for 30% of the frequency and 28% of the time. The other frequent activity where workers spent time was in communication and coordination.

Activity frequencies and time spent by healthcare workers on various activities. Average frequencies represent the number of times a healthcare worker was observed engaging in the activity; frequencies are counted across physicians, residents and nurses. The average time spent represents the time a healthcare worker spent on a certain activity over a 12-hour observation period. The time is reported in decimal hours; for example, 4.8 hours equates to 288 minutes.

For the 12-hour observational period, to see how the activity times were distributed for each role, we separated out the times spent on documentation, direct patient care and the remaining activities by roles (see figure 1 ). Results show that physicians, residents, and nurses spent the highest amounts of time on documentation, compared to patient care or other activities. Further, physicians spent more time on documentation compared to residents and nurses.

Time spent by physicians, residents and nurses on documentation, patient care and other activities. The analyst observed the healthcare workers for 12-hours, so the times in figure 5 represent a 12-hour total.

It is also noteworthy that, on the average, physicians and residents spent more time on documentation than on direct patient care activity (averaged over the 12-hour observation period). Nurses spent about the same time on documentation and patient care.

3.2. Comparison of documentation time and direct patient care time

Given that documentation and direct patient care emerged as the top two activities healthcare workers spent time on, we were interested in comparing the average time for documentation and the average time for patient care. We conducted a paired t-test to compare the time spent on documentation and the time spent on direct patient care. Results (see figure 2 ) indicate a significant difference in the time spent on documentation (M = 4.8, SD = 1.7) and the time spent on direct patient care (M = 3.4, SD = 1.62); t(21) = 2.418; p = 0.02.

Paired t-test between documentation time and patient care time. The box plot with the bar graph includes the 95% confidence interval about the mean, with the mean represented by the dot in the vertical line within the box for each activity. The box plot represents all 22 participants.

To further analyze whether documentation times and patient care times differed significantly by role, we conducted a MANOVA, with the healthcare worker’s role set at 3 qualitative levels (physician, resident and nurse). Results suggest that there is no significant difference between roles considering spent time on documentation, and patient care activities, when considered jointly, Wilk’s Lambda = 0.887, F (4,36) = 0.558, p = 0.695, and partial ɳ 2 = 0.058 (see Table 5 ).

Multivariate GLM with time spent on documentation and patient care activities as dependent variables for the three provider roles (residents, physicians, and nurses).

Besides the MANOVA, to test if the documentation time and the patient care time were significantly different when considered separately, we conducted a univariate ANOVA. Results indicate that there is no significant difference between residents, physicians and nurses in spent time on documentation activities, F (2,19) = 0.275, p = 0.763, partial ɳ 2 = 0.028. Similarly, there is no significant difference between residents, physicians and nurses in the times they spend on patient care activities, F (2,19) = 1.067, p = 0.364, partial ɳ 2 = 0.101 ( table 6 ).

ANOVA on mean differences of time spent on documentation and patient care activities considered separately between roles (residents, physicians, nurses).

4. Discussion

We evaluated how much time healthcare workers spend on documentation, patient care, and other clinical tasks in a hospital with a mature electronic medical record system, which the hospital implemented eleven years ago. When an electronic system becomes mature with time, one would expect healthcare workers to take progressively lesser times for documentation given their increasing familiarity with the system, and because the technical support team for keeping the system running error-free would have ironed out all the kinks in the system.

Our study results, however, are contrary to these expectations for a mature system. Our results show that healthcare workers spend more time on documentation activities compared to patient care. Results also show that a healthcare worker’s clinical role does not significantly influence the times they spend on documentation or patient care; thus, physicians, residents, and nurses, all spend more time on documentation than patient care. Also, statistics on time distribution from our study indicate slight differences between documentation and patient care for physicians and residents compared to nurses. We discuss each study finding further in the following paragraphs.

Finding 1: healthcare workers spend more time on documentation activities compared to patient care activities.

A paired t-test showed a statistically significant difference between the time spent by a healthcare worker on documentation and the time spent by that worker on patient care. The time spent on documentation is more than the direct patient care time.

This finding raises an important question: why do healthcare workers spend more time on documentation even when the electronic documentation system is mature? Previous research has shown that documentation times increase when the technical support for using a new system, available in plenty during initial system implementation, becomes sparse once the system is up and running. It leaves healthcare workers to fend for themselves and learn new system features on their own ( Hakes & Whittington, 2008 ).

From our study observations, though, we can anecdotally state that healthcare workers used support systems only rarely. They were already familiar with the system, so this could not have contributed to the higher magnitudes of documentation times we saw. Similarly, we observed that healthcare workers in our study used only the typical features in the system to complete their everyday documentation responsibilities. We saw no evidence they tried new features - so any learning effects would not have contributed to the high documentation times seen in our study.

We think healthcare workers spend more time on documentation in a mature system for four other reasons. First, because electronic documentation systems are pervasive, and hospitals require their use, this is the principal way in which healthcare workers share information about a patient within their care unit and across other units. Hence, they may find it necessary to supply a greater amount of detail during documentation, details they may have otherwise communicated during an extended phone call or during a face-to-face conversation with another healthcare worker. It is also important to note that healthcare workers do not use documentation systems just for authoring information about a patient. They also use it for reviewing and learning about a patient. This indicates that workers also use documentation to get to know the patient, and thereby perform patient care. This reviewing and learning from the documentation will also add to the documentation time.

Second, the volume of patients and the complexity of patient cases might dictate how much time healthcare workers spend on documentation for each patient. Perhaps with an increase in patient volume, they will have less time available to spend on documentation ( Read-Brown et al., 2017 ) during their shift. Similarly, the underlying complexity of each patient may change the amount of documentation needed and hence, the time spent on documentation. Some studies ( Gottschalk & Flocke, 2005 ; Joukes et al., 2018 ) show that physicians spend time outside their regular work hours on documentation, highlighting the struggle between spending time on patient care compared to documentation. This tradeoff may be important when patient volume is high or when patient conditions are complex. To our knowledge, researchers have not studied these intricate relationships between patient characteristics and the time spent on documentation and patient care.

Third, mature electronic documentation systems have well-established documentation requirements. These requirements might mandate that healthcare workers fill many pieces of documentation every day, thus making documentation activities rote. We know from past research that repetitive and rote documentation requirements to fill pre-populated electronic templates lead to the copy-paste behaviors ( Hammond, Helbig, Benson, & Brathwaite-Sketoe, 2003 ; Wrenn, Stein, Bakken, & Stetson, 2010 ), and result in many information errors. It is possible that the amount of documentation needed is disproportionately high compared to care activities considering that a healthcare worker must complete the same document for a single patient every day even if the patient has been in the hospital for a while.

A related concern is the process of creating a document electronically, and the underlying usability challenges. For instance, because of record-keeping requirements, health providers create many electronic notes and documents every day for a single patient. This means to understand a patient case, a healthcare worker may have to search through several hundred notes and documents to find relevant information. They may also need to open multiple screens and documents at the same time to author new information in electronic notes. The question to ask here is whether all these additional actions contribute to increasing the total time a provider spends documenting.

Finally, documentation, whether paper-based or electronic, has always been important to hospital administrators for demonstrating accountability. That your task is “done only when it is documented” is a widely held belief among healthcare workers (MorrisseyRoss, 1988; Lorman Education Services, 2018). This belief might lead healthcare workers to spend more time in documenting their patient care than necessary.

In exploring the relationship between documentation and patient care activities, two important and related questions emerge. First, given that healthcare workers review documentation to perform patient care, and given that they must document their patient care, are documentation and patient care independent activities? Our view is that the boundary between documentation and patient care is not well-defined and that these two activities feed off each other. This question needs further investigation to inform the methods we use to measure time spent on activities, and to understand how electronic information systems may change the scope and characteristics of healthcare work. Second, can and should health providers reallocate the time they spend on documentation to patient care? Many studies in the past compare the time spent on documentation and patient care with the assumption that the time saved from documentation, when re-allocated to patient care, can improve care ( Banner & Olney, 2009 ; Oxentenko et al., 2010 ; Poissant, 2005 ; Wong et al., 2003 ). This assumption needs a thorough re-examination because caring for patients may only need a fixed amount of time and may not necessarily benefit from any extra time reallocated from the time saved from documentation.

Finding 2: there are no differences between clinical roles in the time they spend on documentation and patient care when considering the times jointly and separately. Finding 3: time distribution statistics show minor differences between documentation and patient care times for physicians and residents when compared to nurses.

Our MANOVA and univariate ANOVA reveal no statistically significant effects of a healthcare workers’ role in the time they spend on documentation compared to the time they spend on patient care. Regardless of their clinical role, they spend a comparable amount of time on documentation and patient care. This result raises an important concern that needs further investigation. Even though workers with different clinical roles perform different patient care activities, they all spend comparable amounts of time in documentation activities. This leads one to question whether documentation requirements have become so pervasive that all clinical roles spend vast amounts of time on documentation.

Although our statistical analyses reveal no significant differences across roles in time spent on documentation and patient care, descriptive statistics on the time spent by nurses, residents and physicians on documentation and patient care show that physicians and residents spend more time on documentation compared to patient care, while nurses seem to spend about an equal amount of time in both tasks.

The literature is inconclusive on whether nurses spend more time on documentation compared to patient care. Our study is convergent with some studies which report that nurses spend an equal amount of time on documentation and patient care, indicating differences in the content, amount, and scope of documentation for nurses ( Korst, Eusebio-Angeja, Chamorro, Aydin, & Gregory, 2005 ; Yee et al., 2012 ).

The differences in the specific activities undertaken by nurses when compared to doctors may explain why we saw differences among nurses and doctors in how they spend their time between documentation and patient care. When we categorize the activities of the healthcare workers into documentation, patient care, and communication and coordination activities, slight differences appear between nurses, physicians and residents. For example, as part of patient care activities, nurses may assess a patient’s health condition, assist in procedures, help ambulate the patient, administer medications and coordinate with other healthcare professionals who provide care. Physicians, on the other hand, as part of their patient care activities may spend time to assess patients and develop diagnoses, make plans for care, engage in education, perform procedures, and make treatment decisions. The patient care activities nurses and physicians perform every day are different, so the time they spend for their required patient care activities will differ.

In addition, nurses may spend less time on documentation compared to physicians or residents because of the differences in documentation requirements. Nurses typically document about their assessment of a patient, the plan of care for the patient, a patient’s vitals and medications, and their pain assessments. They also document discharge summaries. Physicians typically document about the patient’s history and physical exam in the form of progress notes, procedure notes, discharge summaries, and sign-out notes. They also review notes by other healthcare professionals. A recent study by Boyd et al., (2018) compared the discharge summaries of nurses and physicians to assess their relationship through use of unified medical language system (UMLS) and natural language processing analysis. They found that nurses and physicians were different in the terminology they used to create their respective documents; further, they found that the relatedness between the two sets of discharge summaries was low, indicating that nurses and physicians made different contributions to the patient outcomes even for the same patient. By extension, what they document and why they document in the electronic healthcare record also differs and will lead to differences in time spent on documentation. Nurses also spend time on documentation during major transitions such as discharges - we did not specifically analyze the relationship between transitions and the amount of documentation just during those transitions in this study.

Compared to nurses, physicians and residents spend more time on documentation than patient care in our study. Previous studies comparing time spent on documentation versus patient care among doctors portray mixed results, as summarized in our literature review in the introduction section. For physicians, Pizziferri et al., (2005) showed that there was a slight decrease in documentation time after implementing EHR. Ammenwerth et al., (2009) and Tai-Seale et al., (2017) indicated that patient care and documentation took an equal amount of time. Our study findings are most convergent with Joukes et al., (2018) who report that there was an increase in documentation time in one center that implemented EHR, and a decrease in patient care in another. Similarly, the study by Overhage, Perkins, Tierney and McDonald (2001) indicated a slight increase in the time for writing orders a year after implementation of an electronic system. These studies, however, compared documentation and patient care time when studying transitions to electronic health record systems, while our study evaluated the time spent on these activities in a mature and stable electronic system.

Besides the differences in scope of activities between nurses and doctors, billing levels and patient volumes also explain the increased documentation times seen among doctors. A model developed to explore the relationship between billing levels, patient volumes and EHR use in an ophthalmology unit found that an increase in billing levels related to an increase in EHR use time, while increases in patient volume decreased EHR use ( Read-Brown et al., 2017 ). Billing levels and complying to legal requirements are key incentives for documenting patient care and will influence the amount of documentation. An increase in patient volume may not allow enough time for documentation. So, physicians may catch up on documentation outside work hours ( Gottschalk & Flocke, 2005 ; Joukes et al., 2018 ) if increases in patient volumes do not allow enough time to document during regular work hours. Future studies will benefit from considering the interactions between billing levels and patient volume and traffic characteristics to generate a more comprehensive understanding of the differences in time spent on documentation versus patient care.

In summary, the findings from our study that healthcare workers spend more time on documentation and less time on patient care prompt further investigation about the “balance” between documentation and patient care. We need further research to understand what a reasonable amount of documentation is, and what excellent quality documentation should represent. What factors should influence how much healthcare workers document and what they document for every patient? Is there an expectation that healthcare workers must spend the same time for every patient? For example, if the patient’s underlying condition is more complex, would it need more data and a different type of documentation than for a less complex patient? Are patient care and documentation activities distributed based on the number and type of patient a healthcare worker sees, and based on the regulations that might underlie their activities? We posit that understanding if there is a balance between these two critical activities is the more challenging question that needs further study in mature information systems.

Our study evaluated the time spent on patient care, documentation, and other activities in a healthcare setting with a mature electronic healthcare system. We hope that this study will provide an impetus for future studies that examine other mediatory factors such as new regulations, changes in technology, and patient and provider characteristics and their interactions, in influencing documentation and patient care activities.

5. Conclusions

The main goal of the study was to determine the time that healthcare workers spend on documentation compared to direct patient care activities. We found that healthcare workers spend more time on documentation activities compared to patient care activities. The type of clinical role did not have an influence on time spent on documentation vs. patient care activities. Understanding the relationship between external factors such as regulations, technology challenges can make documentation and patient care effective.

• Healthcare workers spend more time on documentation compared to patient care.
• Results hold true for all clinical roles
• Results highlight documentation-patient care tensions in mature electronic systems.

6. Acknowledgements

Both authors were supported by a grant to the second author from the National Library of Medicine, NIH (5R00 LM0111384–03).

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Volume 18 Supplement 1

Selected articles from the 6th Biennial International Nursing Conference

• Open access
• Published: 16 August 2019

Nursing care activities based on documentation

• Mira Asmirajanti 1 ,
• Achir Yani S. Hamid 2 &
• Rr. Tutik Sri Hariyati 2  

BMC Nursing volume  18 , Article number:  32 ( 2019 ) Cite this article

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Nurses engage in various activities from the time of a patient’s admission to his or her discharge from the hospital, helping patients to meet their needs. Each of the activities should be documented properly as authentic and crucial evidence. This study aimed to identify nursing activities in the delivery of nursing care based on the documentation completed.

A quantitative design with a retrospective approach was used, in which 240 medical records from Dr. Kariadi Hospital in Semarang, dating from July through September 2016, were obtained and assessed. The records were randomly selected based on the 10 most common medical and surgical diseases and a hospital stay of more than 3 days. The instrument for collecting the data from the patient progress notes used an observations form. The data were analyzed using univariate statistics and needed to be at least 80% of the values for a certain criteria for it to be considered. The results were analyzed to compare the standard of care.

It was revealed that nursing activities in the delivery of nursing care were insufficient. These activities, according the standard of nursing activities, included the assessment of the functional status of decubitus risk (20.8%), biological status (0.4%), formulation of a nursing diagnosis (20.8%), identification of patients’ home needs (41.3%), quality of life (66.3%), collaboration intervention in drug administration (60.8%), monitoring of vital signs (23.3%), monitoring of daily living activities (37.5%), mobilization/rehabilitation (37.5%), outcome (46.7%), and resume activities nursing (0.8%).

Conclusions

Nursing activities are very important within the hospital and must solve the problems that the patient needs. Every nursing activity should produce documentation with critical thinking. If nursing documents are not clear and accurate, inter-professional communication and an evaluation of nursing care cannot be optimal. Nursing activity and documentation should be continuously directed, controlled, and evaluated by a nurse manager. The quality of nursing activities should always be good to increase patient satisfaction, patient safety, and cost-effectiveness.

Nurses are involved in many activities in a hospital from patient admission through discharge. They provide continuous 24-h patient care, which is divided into several shifts [ 1 ]. Patient care includes performing assessments, stating nursing diagnoses, developing intervention plans, implementing care, and making evaluations to modify or terminate care [ 2 ]. Examples of nursing interventions include discharge planning and education, the provision of emotional support, self-hygiene and oral care, monitoring fluid intake and output, ambulation, the provision of meals, and surveillance of a patient’s general condition [ 3 ]. The delivery of nursing care should involve the patient. A nurse respectfully communicates, coordinates, and integrates nursing care, provides education and information, and considers the comprehensive and continuous physical and emotional comfort of the patient [ 4 ]. In addition, a nurse employs an appropriate strategy to establish a good rapport with a patient and is able to understand a patient’s condition in such a way that they can motivate him or her to actively participate in every nursing activity [ 5 ].

Each nursing activity should consider patient safety. Nurses are responsible for preventing patients from falling and from developing pressure ulcers, urinary tract infections, and nosocomial infections [ 6 ]. They provide education and information regarding the procedures involved in nursing interventions beforehand and involve patients for their own safety; effective communication is the key to patient safety [ 7 ].

Nursing activity that has been completed or that will take place should be properly documented. Accurate documentation and reports play a pivotal role in health services [ 8 ]. This documentation is necessary to identify nursing interventions that have been provided to patients and to show patient progress during hospitalization [ 9 ]. It is also an indicator of nurse performance and the nursing service quality in a hospital. Documentation provides details of patient condition, nursing interventions that have been provided, and patient response to the intervention(s) [ 10 ].

Nursing documentation also serves as an effective tool of inter-professional communication between nurses and other health professionals for delivering ongoing nursing care, evaluating patient progress and outcomes, and providing constant patient protection [ 11 ]. High-quality nursing documentation may improve the effectiveness of communication between health professionals in first- and higher-level healthcare facilities [ 12 ].

The documentation should be saved for an appropriate length of time and should be concise and clear; complete, accurate, and up-to-date documentation will protect a nurse in a court of law [ 13 ]. Correct documentation may encourage a nurse to establish continuity between the diagnosis, intervention, progress, and evaluation of the outcome [ 14 ]. A previous study revealed that 54.7% of nursing documents were of poor quality and 71.6% were incomplete [ 15 ]. Supervision by the head nurse is required for complete, concise, and accurate documentation of nursing care [ 16 ]. The information above provides a platform for managers and nurses to better understand the delivery of nursing care.

A quantitative, cross-sectional, and retrospective study used the medical records of discharged patients. The medical records concerned patients who had been hospitalized for more than 3 days at the medical surgical ward.

Setting and sample

The study was conducted in DK Hospital of Semarang from October until December 2016. Data were obtained from July to September 2016 from 240 medical records of patients with the 10 most common medical surgical diseases. The 240 medical records were randomly selected by simple random methods based on even and odd numbers. Ethical clearance procedures were followed. Medical records data were maintained confidentially, were used only for research purposes, and were not disseminated for other purposes.

Data collection

The authors recorded all nursing activities performed by nurses from the time of a patient’s admission until his or her discharge via an observation form that had been developed by referring to patient progress notes. This observation form consists of nursing activities and had been tested for validity and reliability to achieve optimal data. The validity and reliability results were r Alpha > 0.90 and coefficient kappa > 0.80.

Data analysis

The collected data were assigned codes, inputted into a computer, and cleared of unnecessary information. The data were checked during entry and compilation before analysis. After checking the data for completeness, missing values, and coding questionnaires, data were entered into the computer and analyzed. Univariate analysis was used to identify the frequency and percentage of nursing activities performed. The results were analyzed to compare the standard of care with the hospital accreditation standard and needed to be at least 80% of the values for a certain criteria for it to be considered.

A total of 240 medical records for patients who had been hospitalized for more than 3 days in the medical surgical ward were obtained and analyzed. Data were obtained from the documentation completed by nurses while providing nursing care for each patient. These activities involved patient identification, assessment, nursing diagnosis formulation, discharge planning, education, intervention, monitoring and evaluation, mobilization/rehabilitation, and nursing outcomes. The results are presented in Table  1 below.

The results show that the nurses performance on some nursing activities were below standard (80%). Some nursing activities which needed to be optimized including the assessment of functional status, risk of a pressure ulcer (20.8%), assessment of biological aspect (0.4%), formulation of a nursing diagnosis (20.8%), collaboration in drug administration (60.8%), monitoring of vital signs (23.3%), monitoring of activities of daily living (ADL) (37.5%), mobilization/rehabilitation (37.5%), nursing outcome (46.7%), identification of patients’ home (41.3%), quality of life (66.3%), and nursing activities resumé (0.8%).

The results also indicated that nursing activities were not implemented in compliance with the nursing process; for example, some nurses had not properly performed a biological assessment before proceeding to formulate their diagnosis and perform an intervention. Although the interventions were properly executed, the mobilization and monitoring activities could be improved. Nurses rarely formulated a nursing diagnosis before the expected outcome; however, these two activities should be performed in order, since it may affect the planned nursing intervention. The nurses did not properly identify the patients’ home needs in discharge planning, nor did they create an optimal nursing activities resumé.

The results revealed that nursing activities to solve problems and meet patient needs in the provision of nursing care were not systematically performed and critical thinking was not applied during the nursing process. A previous study asserted that the nursing process incorporates the assessment, nursing diagnosis, planning, implementation, evaluation, and documentation [ 16 ]. The phases in the nursing process are interconnected and become a continuous cycle. Therefore, steps in this process are interrelated, interactive, and cannot stand alone [ 17 ].

It was also shown that some nurses did not perform a biological assessment, yet they proceeded to formulate nursing diagnoses and perform interventions. A nursing diagnosis, however, should be based on the assessment result and used as reference in determining the intervention [ 18 ]. Nurses should consider using a nursing process that complies with the input, process, and output in formulating an intervention, since it may affect the quality of care and patient safety in general [ 19 ]. Patient safety is a fundamental concern for all nurses and health professionals, from the patient’s admission to the hospital until discharge; therefore, it is required that every nursing process is implemented according to the standards applied and in a sustainable manner. If these standards are not observed, then the nurses and other health professionals would not meet patient needs and may even compromise patient safety.

It was shown that nursing activities in identifying the patients’ home needs and quality of life during discharge planning were not properly implemented. Discharge planning is a crucial nursing activity that facilitates a patient’s readiness regarding his or her discharge from the hospital; it allows a patient to be safely transferred from the hospital to their own home. Lack of nursing support in this activity has previously resulted in an increased number of patient readmissions [ 20 ]. Although discharge planning also involves other healthcare professionals, the nurse has the longest amount of time to interact with the patient. The nurse should understand the patient’s condition, recognize their ability to accept it, and improve the readiness of the patient and their family for continuing care at home.

The collaboration intervention of drug administration was not fully implemented. Nurses should provide education regarding the function, composition, and side effects of a drug and adverse reactions that may occur with uncontrolled use. Therefore, a nurse should ensure that a patient has been properly informed of the drug prescribed by a physician. A previous study revealed that collaboration in drug administration in provision of nursing care may improve patient satisfaction and reduce their stress and anxiety [ 5 ].

The findings revealed that nursing activities in vital signs and ADL monitoring were not correctly implemented. Monitoring is a critical nursing activity and identifies a patient’s condition and ability to meet their daily needs so that a nurse may devise an appropriate intervention. A previous study revealed that nurses played a pivotal role in helping patients to recuperate by performing an assessment, monitoring, intervention, evaluation, and provision of support [ 21 ], immediately recognizing a change in a patient’s condition, health promotion, preventing morbidity, improving patient satisfaction, and quality of care.

In the present study, nursing activities in patient mobilization/rehabilitation were not properly executed. Patient mobilization/rehabilitation is an activity that must be implemented immediately after a patient’s hemodynamic parameters are stabilized in order to improve their physical condition. A previous study stated that nurses should pay heed and motivate patients in rehabilitation to ensure effective and cost-effective care [ 22 ].

The present findings also showed that nursing activities in deciding the patient outcome were not optimal. The determination of outcome serves to evaluate how much progress has been made by a patient following the delivery of nursing care. Indeed, one study claimed that the determination of outcome reflected the unique contribution of nursing care toward patient safety [ 23 ].

The present findings of improper nursing activities may have resulted from numerous factors, such as having to perform a large number of non-nursing duties, manual documentation, a lack of standards in documenting patient progress notes, and the exclusion of nursing care in calculating remuneration.

All nursing activities should be properly documented as authentic information and used to evaluate nursing care and professional competency. Nursing documentation is an essential component of professional practice to improve the quality of nursing care and should be accurate and complete [ 24 , 25 ]. Complete documentation encourages nurses to work effectively and appropriately [ 14 ].

Some nursing activities have been done properly, but they were not continuously in compliance with the nursing process. Nursing care was not systematically performed and critical thinking was not applied during the nursing process. Many nurses did not do a biological assessment, yet they proceeded to formulate nursing diagnoses and perform interventions. Nursing activities in identifying patients’ home needs and quality of life during discharge planning, collaboration intervention of drug administration, vital signs and ADL monitoring, patient mobilization/rehabilitation. and deciding the patient outcome were not properly implemented.

The nursing process should be properly implemented in order to improve patient and nurse satisfaction, quality of care, patient safety, and cost-effectiveness, as well as to reduce the average length of stay. A nurse who has completed nursing activities is required to document the care provided, according to the standard applied. Nursing activities and documentation may be more likely to be optimal if they are regularly directed, controlled, and evaluated by the nurse manager. A nurse and patient satisfaction survey should also be periodically conducted to evaluate the quality of nursing activities in the delivery of nursing care for patients.

Abbreviations

Activities of daily living

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Acknowledgements

The authors would like to thank the Faculty of Nursing, Universitas Indonesia for financial support. Their grateful thanks also go to the informants who participated in the study and openly shared their thoughts and experiences.

The publication cost of this article was funded by PITTA Universitas Indonesia grant, under grant no.365/UN2.R3.1/HKP.05.00/2017.

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The data and materials used for analysis and make conclusion are available from the corresponding author on reasonable request.

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This article has been published as part of BMC Nursing Volume 18 Supplement 1, 2019: Selected articles from the 6th Biennial International Nursing Conference. The full contents of the supplement are available online at https://bmcnurs.biomedcentral.com/articles/supplements/volume-18-supplement-1 .

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Mira Asmirajanti

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Achir Yani S. Hamid & Rr. Tutik Sri Hariyati

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All authors contributed to the writing and editing of the manuscript. All authors read and reviewed the final manuscript. All authors read and approved the final manuscript.

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Asmirajanti, M., Hamid, A.Y.S. & Hariyati, R.T.S. Nursing care activities based on documentation. BMC Nurs 18 (Suppl 1), 32 (2019). https://doi.org/10.1186/s12912-019-0352-0

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Point of care documentation impact on the nurse-patient interaction

Affiliation.

• 1 Evanston Hospital, NorthShore University HealthSystem, Evanston, IL, USA. [email protected]
• PMID: 20023554
• DOI: 10.1097/NAQ.0b013e3181c95ec4

Electronic medical record (EMR) point-of-care (POC) documentation in patients' rooms is a recent shift in technology use in hospitals. POC documentation reduces inefficiencies, decreases the probability of errors, promotes information transfer, and encourages the nurse to be at the bedside. However, EMR POC documentation has the potential to distract the nurse's attention away from the patient and compromise the nurse-patient interaction.

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