Documentation Time

Published

I am not a nurse but have spent many years as a clinical engineer in both hospitals and outpatient clinics. My question to the group is how much time during a normal shift is spent on documentation. Then how much of that time is spent documenting vitals signs, patient assessments (such as pain or sedation scores) or settings from medical devices. How much of this is paper or electronic or both? and Finally has your documentation time increased or decreased with the use of EMRs.

Thank you in advance

Tracy

Up Vote Up Vote ×
Specializes in Emergency & Trauma/Adult ICU.

First, I have a question for you.

What is a clinical engineer? What's your educational background? What are your job responsibilities?

OK ... I guess that was more than one question ...

Up Vote Up Vote ×

A clinical engineer is officially someone who applies engineering practices to health care and the practice of medicine. I have a masters degree in engineering and prior to be certified I am required to spend at least 4 years working the the health care environment. Personally I have spent 8 years in the research word, evaluating patients and collecting research data alongside nurses, physicians, and therapists. I then spent 3 years working for a large integrated health system in the US working point of care device installations.

On a day to day basis I evaluate technology, make recommendations on the quality and safety of medical devices. Plan and coordinate device and information systems implementation. I evaluate devices for cause of failure or usability. And on rare occasions I have to get my hands dirty and fix something . I also spend a large amount of my time providing clinical staff in services on new equipment (normally i provide refresher trainer for nursing practice coordinators) and providing administration evaluations of equipment, estimating project costs and advice on new and innovative equipment.

It isn't a new field but there is only about 1000 people in the US who have the title of clinical engineer. Large health care systems and research hospitals employ most of us. One of the areas this field is moving towards is evaluating system events in health care this includes the people in the process as well as the technology and how they work together.

Prior to my current position I spent an average of 4 days a week in the clinic trying to make clinical staff lives a little bit easier to understand what they really needed and if what the administration thought they needed matched up.

Hope that helps.

Up Vote Up Vote ×
Specializes in ED, ICU, PSYCH, PP, CEN.

I couldn't put a number on it, but I bet at least 25 percent of my shift, if not more, is spent documenting. This is because everything I give, do, and or say to a patient or their family must be documented.

That is, give a drug, document it, turn a patient, document it. So all day I am running to write, or put this in computer.

Also, many forms to fill out. Dog bite, DCFS, restraints, consents, the lists go on and on.

The best way to learn how much time is spent on documentation would be to shadow a nurse and count the documentation time. Of course you would need to compare nurses that chart on computer, versus those who still must chart on paper.

Sadly, we are being forced to double document a lot of things now, which takes up even more time. For example, an IV start has to be documented on 3 different forms.

Up Vote Up Vote ×
I am not a nurse but have spent many years as a clinical engineer in both hospitals and outpatient clinics. My question to the group is how much time during a normal shift is spent on documentation. Then how much of that time is spent documenting vitals signs, patient assessments (such as pain or sedation scores) or settings from medical devices. How much of this is paper or electronic or both? and Finally has your documentation time increased or decreased with the use of EMRs.

Thank you in advance

Tracy

I am sorry for my cynical nature. But I imagine data like this being collected by someone with no sense of clinical realities, and then by "Workplace redesign' suddenly a non-medical person decrees that I am "wasting so much time', so now my workload will greatly increase.

Up Vote Up Vote ×

I was thinking the same thing........:angryfire

Up Vote Up Vote ×

I completely understand the cynical apprehension. I have spent quite of bit of time already observing nurses and what I am currently working on is methods to decrease double documentation, especially in the electronic format.

I am not working on work flow redesign, but how new technology needs to meet the clinical staff somewhere in the middle. An example is automatic verification of infusion pump settings (from the pump directly) with the orders and dosage guidelines, then the automatic documentation of those settings at the bedside along with vitals. Thus generating the complete set of documentation (shift dosage, vital signs, pain, sedation score, etc) with a single input, single form of documentation, and the safety checks which all it requires is you to verify and sign. If the administration needs 3 forms then let them be created automatically.

There is no point adding a system which adds more work for the clinical staff and doesn't give the clinical staff anything back. From other sources I am seeing a consistency that 25-30% of nurses, and therapists time is spent documenting with a lot of double documentation all I am saying is from what I've observed it should be made easier so you can be nurses and not data entry people. Thank you for your responses.

Up Vote Up Vote ×
Specializes in Utilization Management.

When I worked night shift, I'd say I spent over 50% of my shift working on charts.

When I came in, I assessed and got vitals for all of my patients. I then had to chart manually to a flow sheet all of the normal things found. Abnormals were noted differently with details provided in the nursing progress notes.

We then had to check off the Braden scale daily and do education for each patient, and then fill out those forms. Finally, we were to complete the patient's care plan by generating and then evaluating the plan of care for each patient.

We copied new medicines to the MAR, and every few days, had to recopy the MARs themselves.

We checked the day's orders off against what was in the computer.

A lot of our time was spent tracking things that somehow slipped past the other nurses. For instance, we'd find an order for a stat 2DE that was not done since day shift. Original tech that did 2DE's was home, so we were unable to call and find out why.

Hopefully the nurse or the doctor documented in the progress notes, "Patient refuses 2DE." If not, we'd have to call the department and sometimes literally wake people up to find out why the test was not done.

Doctors were particularly unhappy about 0300 calls, so we tried to call on those items around 0600 - 0700. (And we couldn't win there either, because they'd get upset and ask why it couldn't wait till day shift, when the obvious answer was that we don't stay past 0700, so if a correction needs to be made, it's our baby and we have to have time to fix the error completely).

However, if it was something serious, say that we were having a great night until it was discovered that someone missed giving a unit of blood or having a stat CT head, then we had to complete the orders, call the doc, and file an incident report (which involved phoning 3 more people in administration, in addition to sometimes having to notify the patient and the family -- all generating even more documents).

And don't get me started on the amount of paperwork and redundant documentation that's generated with an admission or a discharge, or even the patient who decides to walk out AMA.

It's a wonder we don't all have carpal tunnel, I tell ya. :lol2:

Up Vote Up Vote ×
+ Join the Discussion