We have found that eliminating unnecessary nursing documentation increases the accuracy and usefulness of the medical record, enhances communication, reduces nursing-associated adverse events such as falls, and improves compliance. It is a fundamental approach to solving CMS/state agency compliance problems. It is a win-win-win for nurses, physicians, and (most importantly) patients – and survey agencies are the biggest advocates for the change.
Simplification also helps us develop the critical thinking skills of our front-line nurses. When we give in to an ocean of clicks and drop-down menus, we give up individualization. By stripping away unnecessary information we begin to see the patient and their evolving condition and progress.
So, what can be eliminated? Here’s a brief outline (hold on to your hats … there are a lot of myths we’re about to bust):
Separate nursing care plans: The necessary elements of planning, intervention, and evaluation being a simple part of—and result from—the nursing assessment/reassessment.
Admission assessment: Some clients can eliminate 85% of the information collected upon admission. Many elements are NOT actually part of a “head-to-toe” physical assessment, and many elements are captured elsewhere by other disciplines (such as in the physician’s H&P), or simply do not enhance the true picture of the patient’s condition or further the clinician’s knowledge about how best to provide care.
Shift/ongoing assessment: Here again we’re able to reduce the burden by 75–80%.
At the end of this simplification effort nurses are given back the time to care for patients, the care team can track the progress of the patient by reading the streamlined nursing notes, critical thinking skills are visible and can be reinforced, there are fewer falls and skin breakdowns, and regulators are very, very happy. Remember our goal is to increase communication, support the nursing process, and enhance compliance, all of which are accomplished as a result of simplification.