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Nursing Informatics & Technology: A Blog for All Levels of Users

The Documentation Paradox in Med-Surg

Published September 17, 2014 9:00 AM by Susan Niemeier, RN, BSN, MHA
The med/surg unit is an operationally intense care environment with typically two out of three hospitalized patients residing in this area. The acuity of patients in this setting is escalating, along with rising co-morbidities and patient age. In parallel, the hospital's patient population is shifting more toward outpatient care, increasing the number of short-stay patients. Short-stay patients are those who stay in the hospital for approximately 23 hours or less and are then discharged to go home. Often, these patients are placed in med-surg units and require a heightened level of observation to assess for subtle changes in their condition. As acuity increases, so do the number of devices at the bedside, along with the requirements for entering data into a patient's record.

Despite these conditions the nurse-to-patient ratio in med-surg units has not changed. This results in more work and immeasurable stress. Add to that the regulatory, legal and hospital compliance efforts for higher degrees of documentation, as well as pressure to discharge patients as soon as possible, and you can see that there is a "perfect storm" of increased workflow requirements that could lead to errors putting patients at risk.  

The environment wherein med-surg nurses work has become incredibly complex and demanding. The result is that they must provide increased effort, energy, and attention just to perform their normal, daily activities. Many are close to the breaking point; they simply cannot take on any more work or responsibility without significantly impacting patient care.

One responsibility that steals substantial time from patient care is documentation. The increasing complexity of patients seen in the med-surg unit means that nurses are constantly moving (between one and five miles during a typical 10-hour shift), making decisions on the fly, and multitasking, all of which takes a high toll on performance and work processes.1 Given all this, nurses view documentation as a lower priority item on their list, choosing to document in batch mode when they have a few minutes rather than in the real time.

In fact, studies find that it takes between two to twelve hours after collecting data from patients' monitors before nurses enter it into medical record. The manual entry of data leads to error rates as high as 17%.2 Yet documentation is taking up an increasing amount of nursing time, with studies finding that 35% of a nurse's time is spent on documentation (147 minutes in a 10-hour shift), while less than 20% is spent on patient care and education, and just 7% on assessment and surveillance.3

The focus on quality in today's healthcare environment means the EMR must be fully integrated into clinical care and decision making. Among the benefits when used properly, for instance, are better decisions and better coordinated care. With physician order entry, physicians need an ‘information rich' record with real-time data. Ancillary departments such as respiratory, physical, occupational and speech therapy also require access to an up-to-date medical record so they may immediately know a patient's state. Such information is equally important for pharmacy, infection control and discharge planning.

However, while EMRs can bring numerous benefits to the hospital environment and improve patient care, they are impractical and even dangerous if the data is not accurate, timely, and complete. So, therein lies the paradox: much of the data entered into an EMR is on the shoulders of med-surg nurses. Yet med-surg nurses are forced to place this task towards the bottom of their list because of their patient care priorities.

The current system relies on the nurse to function as a "human bridge" between medical devices and the EMR. The med-surg unit is no exception. Med-surg nurses capture patient data throughout the day from a number of devices, manually writing the data on a clipboard, sticky pads, paper towels or even alcohol wipes. At a later time during the shift, they key the data into each of their patients' electronic record. The danger of this approach is the increased likelihood of errors and potential for omissions. Moreover, valuable time slips by - time during which critical decisions are made based on data that could be hours old. Just as important, all of this activity of capturing data from various bedside devices and manually keying it into a record takes the clinicians away from direct patient care and surveillance, which can affect outcomes. Very simply, under the current system, clinicians doing both clinical documentation and patient assessment simultaneously is ... well ... incompatible, to put it lightly.  

There are solutions to this "human bridge" problem that can remove the nurse as the "middleman". There is increased focus on the automation of clinical documentation, that is:  the electronic transfer of data from a medical device to the EMR, and other clinical systems. The integration of data in med-surg is even more critical as the patient acuity rises along with the number of number of bedside devices to assist in monitoring. Due to the fundamental nature of vital signs, devices that take these measurements are typically among the first to be targeted for automation. Integration, however, is not limited to devices measuring vital signs. Other types of devices that can be integrated in med-surg include (but not limited to) scales, smart beds, infusion pumps, etc. By not having to record and transcribe information into the EMR, a considerable amount of time can be saved. And, automating the collection of data ensures that all desired information is accurately collected. This eliminates the possibility of accidentally omitting essential data during documentation. Recording patient data at a higher frequency allows for catching subtle changes in a patient status much sooner. 

In an environment where information is recorded automatically into the patient's record, there is no need for a physician and the interdisciplinary team to wait on the med-surg nurse to complete rounds and transcribe the data.

In the end, bringing a flexible, documentation automation system into med-surg can help reinvest nursing time to direct patient-care activities, improve nursing productivity and satisfaction, enhance the completeness of the medical record, and ultimately, improve the delivery of safe, high quality care.

My question to you is, why do hospitals choose not to automate device documentation in med-surg when the evidence is clear?


1. Potter P, Boxerman S, Wolf L, et al. Mapping the nursing process. J Nurs Adm. 2004; 34(2):101-109

2. Wager KA, et al. Comparison of the Quality and Timeliness of Vital Signs Data During a Multi-Phase EHR Implementation Computers in Nursing. CIN: Computers, Informatics, Nursing. 2010; 38(4):205-212

3. Hendrich A, Chow M, Skierczynski B, Zhenqiang L. A 36 hospital time and motion study: How do medical-surgical nurses spend their time? The Permanente Journal. 2008;12(3):25-34


Nursing Informatics & Technology: A Blog for All Levels of Users : The Documentation Paradox in Med-Surg

November 16, 2014 8:36 AM

Nursing Informatics & Technology: A Blog for All Levels of Users : The Documentation Paradox in Med-Surg

November 9, 2014 7:36 PM

As Julie points out, cost is definitely a huge consideration. There are, however, other factors that undoubtedly play into these types of decisions. In order for all of that data to be automatically recorded, for example, the patient must be constantly connected to the measuring devices. Most patients, unless very ill, are going to balk at being tethered to the bed by this machinery for no reason other than data collection. That will negatively impact patient satisfaction -- also an important consideration -- as the use of automated equipment may be perceived as a way of work avoidance rather than work enhancement. Not to mention that enforced inactivity is counterproductive in supporting healing.

A second consideration is that, while there is evidence that the quality and timeliness of data collection is enhanced by these processes, this does not necessarily translate into improved care. For it to be useful that data needs to be transformed into information -- contextualized and interpreted. The highest quality, most timely data is useless if it isn't being analyzed. And that analysis, in order to effect treatment, must be done by humans. Automated data collection, unfortunately, in exactly the high activity environment you describe is unlikely to be evaluated by the nurse in a timely manner. At least when data is manually collected, the nurse is aware of the data and may be moved to act, rather than relying on automated data collection with analysis of that data pushed off until another time.

Kevin`, Educator September 20, 2014 9:55 AM

For many institutions, the question is not if, but when will they integrate data into the EMR. I doubt you  would find many facilities that do not understand the benefit of the integration you describe. It boils down to budgetary constraints in a very cost conscious industry. For most institutions, vital sign machines and monitors are not easily or quickly upgraded to a model that will allow integration directly. These are pieces of equipment that, for the most part, are used to and sometimes beyond their expected life spans due to capital budget constraints. Most models do not have the bandwidth to allow integration. In order to make that jump, it takes years of planning and a commitment to use the capital equipment allocated for the revision of the EMR and the replacement of the monitors in a coordinated effort to make the leap worth the effort. We all know that equipment costs are a huge part of a unit budget each year. Everyone has to be willing to make that monetary leap in order to get "perfectly functional" equipment to be replaced in order to integrate. Getting the buy-in from the whole team to do that when other priority items exist is difficult.

Julie, Nursing Informatics - Consultant September 17, 2014 2:00 PM
Seabrook TX

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    Occupation: Nursing informatics experts and enthusiasts
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