When Gwinnett Medical Center in Lawrenceville, GA, decided to cut nursing paperwork by 50% to increase nursing time at the bedside, it was an all-hands-on-deck approach.

“What we found was that it was the paperwork that was keeping us from patient care,” says Deborah Briese, RN, BSN, CCRN-CMC, who is in charge of Provision of Care chapters for the facility.

In October 2007, medical-surgical leadership chartered a nursing documentation team to address the issue. Team membership included the director of medical-surgical nursing, a clinical manager, a clinical nurse specialist, a clinician, Briese, and three staff nurses.

More than just a remake

“I was impressed with the assembled team of nurses,” says Pat Pejakovich, RN, BSN, MPA, CPHQ, senior consultant for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. “They were excited about the work they were doing and very determined to ensure that the end product was not just a remake of their current assessment tool.”

The team analyzed the data clinical indicators and determined that although they could make some minor changes to the current paperwork, it would not be enough.

“As we got into it, we knew that a total revision would be required,” says Briese.

“This is an excellent example of nurses taking charge of nursing documentation and not being afraid to create methods that are innovative and on the cutting edge,” says Pejakovich. “They have developed documents that are focused and useful, which allows them more time to deliver nursing care to the patient.”

Since October 2007, the team has taken a 10- to 12-page nursing assessment with different pathways for plans of care and created a 24-hour assessment and plan-of-care form for the general medical-surgical patient. The team chose the medical model and used the head-to-toe assessment.

“We decided to start there because the tool we had developed would hit 80% of our patients,” says Briese.

The administration database was also revised and streamlined. The former clinical pathway face sheet was revised and renamed the patient care organizer, which has information that is used throughout the patient’s hospital stay.

“Our charting consisted of a lot of checkboxes,” says Briese. “There was redundancy in the documentation with duplication in different places.”

The team received guidance from the saying “Good nurses don’t need checkboxes, and checkboxes don’t help bad nurses.”

The new assessment form defines what “within normal values” are, so if a nurse found a system is “within normal limits,” there would not be a need to address interventions and outcomes. However, if, for example, the nurse found an issue with the lungs, that nurse would record the finding and document planned interventions.

Focusing on the patient

By eliminating duplication in the documentation process, Gwinnett has provided its nursing staff with a chance to get back to “the basics of assessing the patient’s condition from head to toe, intervening, planning, consulting other disciplines, and communicating to patients’ families,” says Briese.

“It’s an opportunity to get back to what nursing really has control over,” she says. “While it is clear from initial reactions that the nursing staff is excited to have less paperwork, it is too early to fully assess the impact of the changes.”

Although patient care was the driving force behind revamping nursing documentation, the other reality, Briese says, was that Gwinnett was finding it increasingly difficult to retain and recruit nurses because of the amount of paperwork involved in nursing documentation at the facility.

Source: Briefings on the Joint Commission, an HCPro, Inc., publication.