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Article history: A small scale documentation analysis was conducted to explore the medical and surgical nursing
Received 24 August 2009 content of the patient record at a large teaching hospital affiliated with Partners Healthcare System
Accepted 27 August 2010 (PHS), in preparation for a computerized documentation system. Through this study, we identified a
number of problems associated with the paper record that require resolution in the new computerized
Keywords: system, including elimination of documentation redundancy, areas where more structure is needed to
Nursing documentation properly capture data on nursing practice, and various design considerations to support a more
Content analysis complete and accurate documentation of nursing care.
Electronic documentation system & 2010 Elsevier Ltd. All rights reserved.
0010-4825/$ - see front matter & 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.compbiomed.2010.08.006
H. Kim et al. / Computers in Biology and Medicine 41 (2011) 182–189 183
in richer documentation. Patient’s length of stay varied from 2 to assessment data that would have led to the nursing problems
34 days. We reviewed the first 2 days of the stay. from the admission assessment form; continuous assessment and
The purposes of this chart review were to investigate (1) intervention data relevant to the identified nursing diagnoses
whether the key information on carrying out nursing care is from the flowsheets and the progress note. During the chart
captured in the current documentation with sufficient depth and review we also collected all of the free-text entries made to the
breath to comprehend how the nursing care was determined, free-text field of the flowsheet labeled as ‘‘nursing observation’’.
planned, and provided; (2) what kind of information was The data obtained from the chart reviews was entered into a
documented in the free-text field ‘‘nursing observation’’ of the Microsoft Access database designed to guide the process and to
ICU flowsheets. facilitate consistency of data collection.
Through the chart review we collected six of the seven data After the completion of chart review we created a database
types that current paper-based documentation intends to capture application to evaluate the documentation completeness of the
(as described in the background section of this paper). We excluded nursing care. This application displayed each nursing diagnosis
the ‘‘synthesis of patient status toward indentified nursing goals’’ with other types of data including associated goals, planned
from the analysis for two reasons. First, this type of information has interventions, baseline assessments, continuous assessments, and
already been recognized as poorly documented: nurses often use continuous interventions. Each type of data was evaluated with
the progress note to record assessment data that are not three ordinal categories: ‘‘Acceptable’’—the data was relevant,
documented on the flowsheet, or to repeat the assessment data provide enough information on the related nursing care, and
already documented somewhere else on the flowsheet. Second, the expressed in a clearly understandable way; ‘‘Somewhat accepta-
gist of the synthesis information should be reflected in continuous ble’’—the data was relevant and expressed in a clearly under-
assessment thus focusing on evaluating documentation quality of standable way, but not enough to provide complete information
ongoing assessment data was considered of greater importance. on the nursing care; ‘‘Unacceptable’’—either related data was
Therefore, the specific review process included the collection nonexistent, irrelevant, or expressed in an incomprehensible way.
of the six data types: nursing diagnoses, expected goals, and The 4 nurse reviewers collaboratively evaluated a small number
planned interventions from the plan of care forms; baseline of cases for training, then divided the remaining cases and
H. Kim et al. / Computers in Biology and Medicine 41 (2011) 182–189 185
A total of 1293 documentation items were collected from the 4.2. Documentation of the nursing care
25 forms. The number of items was reduced to 1048 when
counted only the unique (i.e., normalized) ones, indicating about We retrieved 81 nursing diagnoses from the 20 patient
23% of them are currently documented in multiple places. More records. The number of diagnoses assigned to patients varied
than half of the items fell in the assessment category. About a from 1 to 7. The 81 diagnoses were grouped into 13 areas. We did
quarter of the items did not fit into any care process categories not use the care component categories this time because they
thus grouped as ‘‘other’’ (see Table 1). were too abstract to represent the problem areas. The majority of
The most common mode of data entry was free-text (59%) and the problems were related to the physiological status. ‘‘Cardio-
Boolean (30%). Only 11% of the items were documented using pre- vascular’’ and ‘‘Skin Integrity’’ were the two most frequently
defined pick-lists. Twenty four (2.3%) of the 1048 unique items appeared problem areas (see Fig. 6).
were from standardized assessment scales. The evaluation categories assigned to the 6 types of data were
The distribution of the care component categories are converted to numeric scores: ‘‘acceptable’’ to 2, ‘‘somewhat
presented in Fig. 5. The most frequently used category was acceptable’’ to 1, and ‘‘unacceptable’’ to 0. The continuous
‘‘health behavioral’’ and psychological categories (i.e., self- assessment data was the best documented type of data, with an
concept, coping) were among the least. Eighteen items that were average score of 1.47, and the planned intervention was rated
unrelated to nursing care (e.g., room number, time of unit arrival, least acceptable, with an average score of 0.01. The average score
etc.) were not assigned to care component categories. of the nursing diagnoses was 1.17.
186 H. Kim et al. / Computers in Biology and Medicine 41 (2011) 182–189
Average score
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7
cardiovascular (n=16)
pain (n=12)
respiratory (n=12)
neurologic (n=6)
infection (n=6)
nutrition (n=6)
safety-fall (n=4)
education (n=2)
Problem
urinary elimination (n=1)
Goal
gastrointestinal (n=1) Planned Intv
Baseline Assess
mobility (n=1)
Cont. Assess
metabolic (n=1) Cont. Intv
The six scores were added up then divided by the possible Indeed, when compared by problem areas, the ‘‘neurologic’’
maximum total score of 12 to calibrate the overall score to 0 to 1 area was the best documented, with and overall average score
for easy interpretation. The overall average score of the 81 of 0.58.
documentation cases was 0.43. The highest scored case, with The lowest overall average score was 0.08 and it belonged to
0.83, was the one with the nursing diagnosis ‘‘potential for the case with the nursing diagnosis of ‘‘potential for alteration in
change in neurologic signs due to intraventricular hemorrhage,’’ endocrine function,’’ where no other related data was found. The
where the reviewers considered that the quality of the ‘‘metabolic’’ was the lowest scored problem area as this case was
associated goals, the baseline and the continuous assessment its sole member. Fig. 6 shows the overall average score of each
data, and the continuous intervention data were all acceptable. problem area. The average score of each type of data were divided
However, this case did not have any planned intervention data. by 12 for easy comparison.
H. Kim et al. / Computers in Biology and Medicine 41 (2011) 182–189 187
Table 2 documented as free-text thus entry field labels of the forms and
Frequency distributions of the free text entries by the care component categories templates are unlikely to reflect specific diagnosis concepts.
and by the relevancy to the field.
However, we found the low fraction of intervention items
Care component Relevant Irrelevant potentially problematic. Improving nursing sensitive outcomes
is gaining increasing attention [12]. However, accurately defining
Health behavioral 11 1 and evaluating ‘‘nursing sensitive’’ outcomes will be challenging
Activity 6 1 without adequate documentation of nursing interventions.
Physical regulation 5 0
Cognitive 3 5 (5)
Although the coverage was somewhat unbalanced, the dis-
Skin integrity 2 2 (1) tribution of the care component categories shows that the current
Bowel/gastric 1 1 documentation covers the various nursing care domains repre-
Coping 1 0 sented by the categories. However, current documentation seems
Sensory 1 3
less focused on psychological aspects of nursing care. The new
Fluid volume 0 2 (2)
Medication 0 2 documentation system needs to consider enhancing the psycho-
Respiratory 0 2 (1) logical documentation.
Self-care 0 2 Since the ‘‘health behavioral’’ category is defined broadly as
Column total 30 21 nursing activities related to maintain and regain the health status
In parentheses are the numbers of entries that are nursing observation related but
of the patient [10] various content items could be related to it,
have other designated fields to document. from care coordination to patient education. Indeed, the majority
of the items categorized as ‘‘Other’’ in Table 1 were health
behavioral items. A few examples of these items are arranging
4.3. Use of the ‘‘nursing observation’’ field diagnostic test, handling patient belongings, obtaining contact
information of the long term care facility, among others. This
A total of 51 unique entries collected from this field were shows that nurses’ responsibility for documentation is stretched
classified into the 12 care component categories (see Table 2). to non-clinical (‘‘housekeeping’’) data. In addition, this implies
Most of the entries falling in the ‘‘health behavioral’’ category that the ‘‘assessment,’’ ‘‘diagnosis,’’ and ‘‘intervention’’ categories,
were describing disposition of a patient (e.g., ‘‘to angio,’’ ‘‘back to which reflect the problem solving oriented aspect of nursing care
the floor’’). Most of the entries of the ‘‘activity’’ category were conducted through the nursing process, are not sufficient to
describing a patient’s activity status (e.g., ‘‘out of bed to chair,’’ capture the health coordination and management aspect of
‘‘sitting in chair for 40 min’’). About 60% of the free text entries nursing care provided outside the nursing process.
were deemed relevant to the field as they described a kind of The number of data items was reduced by 23% when only
nursing observation, which has no other field to document in the unique items were counted. To identify whether these repeated
flowsheet. Nine entries were deemed irrelevant to the field, even items reflect true redundancy in documentation, we looked at
if they described a nursing observation, because they had a whether any data items appear multiple times in a single form.
designated field to document in the flowsheet (in parentheses, About half of the repeated items were spread in ten forms.
Table 2). The remaining 11 entries were deemed irrelevant as they The number of repetition of one item in a single form varied from
described interventions (e.g., administering PRN medication). 2 to 4. Most of the repetitions were not true redundancy because
Although there was no designated field for these entries in the they were to capture the data at different time points (e.g., vital signs
flowsheet, the flowsheet provides a field labeled ‘‘additional data,’’ measured at pre-procedure and at post-procedure). However, we
which should contain this type of intervention data. observed a few true redundancies: ‘‘whether the patient is pregnant’’
was asked twice to assess nutritional requirement and sexual/
reproductive status, ‘‘history of major surgery’’ to assess nutritional
5. Discussion requirement and venous thrombo-embolism risk assessment. These
items could be unified into a single item in the computerized system
We observed many problems that paper-based documentation and let the system carry forward the data to the places that require
systems commonly have, such as non-standardized documenta- the same information.
tion field labels, frequent use of free-text descriptions and Analysis on the data items appearing in multiple forms to
inconsistent use of free-text fields. Studies showed that these determine documentation redundancy was not done in this study
problems can persist in a poorly designed EHR [2–4]. Despite the as it requires considering documentation workflow and temporal
fact that our study had a very narrow scope and employed information. However, this analysis will need to be done in the
subjective measurement methods that limit the generalizability future study to obtain more accurate insights on documentation
of findings, we have gained some useful insights on how to redundancy.
configure a computerized bedside documentation system at PHS. It is not surprising that the majority of the 81 nursing
We observed that many documentation items are presented problems that we had collected by chart review were related to
with different lexical forms. Recognizing them as synonymous physiological status because the scope was limited to medical or
items is critical to avoid redundant documentation and accurate surgical ICUs. However, unlike our positive expectation on
processing of the documented data in the computerized system. documentation quality in ICU settings, the 20 patient charts
In order to do so, the irregular item names will need to be investigated in this study were deemed failing to deliver sufficient
standardized in the computerized system, or encoded with and accurate data on problem solving oriented nursing care.
standardized terminology systems. Frequent use of free text Two major problems leading to the failure were identified. The
entries also means that developing standardized coded value sets most frequently observed problems were incomplete documenta-
(e.g., pick-lists) for many free-text items needs to be included as a tion. The data required to understand the complete picture of
high priority task in designing the new documentation system to the nursing care (i.e., the six types of data) was often not found
support reuse of the documented data. in the records that we had reviewed. This seems to be a common
From the forms and templates analysis, we found that nursing problem identified by other nursing documentation studies
documentation focused mostly on capturing assessment data. [7,13,14]. We believe the most significant contributing factor
Paucity of diagnosis items was expected as they are usually to this problem is a poor documentation design that fails to
188 H. Kim et al. / Computers in Biology and Medicine 41 (2011) 182–189
support: (a) the capture of data required for carrying out nursing documented in the progress note. Instead, the progress notes
care and (b) nursing workflow. For example, the plan of care form were used to document assessment data that could have been
contains a list of pre-defined intervention categories, which may recorded in the flowsheet. This persisting problem will also need
or may not be relevant to the identified nursing problem. to be further investigated in a follow up study.
However, it does not provide enough space to document
additional interventions. This design issue might lead to the poor
documentation quality of the planned interventions. 6. Conclusion
Nurses are likely to take a process similar to our chart review
process to review the patient data to understand the status of The first step toward developing a computerized documenta-
the care they are providing. Although the chart review was tion system that supports complete and accurate documentation,
limited to the 4 major forms, we found that browsing the paper as well as reuse of the documented data, is to understand the
records to find relevant data scattered in disparate places was an problems of an existing paper-based documentation system.
extremely inefficient process. To address these issues, the Through this limited scope analysis on the nursing documentation
documentation system design team at PHS is conducting content, we gained a number of useful insights on designing a
extensive analyses on workflows in relation to documentation computerized documentation system at PHS. Some of the most
content. The team is also building terminological foundations relevant insights include the extent of redundancy in the
of the documentation content to ensure that the new documenta- documentation content, areas where more structure needs to be
tion system will enable efficient retrieval and presentation of the introduced to capture the data on nursing practice more
relevant data while minimizing manual browsing and searching completely and accurately, and multiple design considerations
for the data [15]. for supporting the capture and display of critical data to support
Improper writing style was another frequently encountered patient-centered nursing care.
issue. This issue was found mostly in diagnostic statements. A
diagnosis and a goal should be stated with enough specificity to 7. Summary
guide the relevant interventions and outcome evaluations.
However, the diagnostic statements that we had reviewed often A small scale documentation analysis was conducted to explore
failed to include relevant details, e.g., potentiality and associated the medical and surgical nursing content of the patient record at a
factors, which are required to determine relevant interventions. large teaching hospital affiliated with Partners Healthcare System
For example, ‘‘potential for altered skin integrity related to (PHS), in preparation for a computerized documentation system. The
pressure ulcer’’ and ‘‘altered skin integrity related to surgical analysis consisted of 2 parts: (1) analyzing 25 existing structured
treatment’’ are two distinct diagnoses that require different sets forms to investigate the nature of nursing documentation; (2)
of interventions. However, they were often poorly stated as reviewing 20 sets of nursing care plans, admission assessment
‘‘altered skin integrity’’ or ‘‘skin integrity’’. forms, flowsheets, and nursing progress notes randomly selected
Retrospectively evaluating documentation completeness is a from ICUs, to investigate the completeness of nursing documenta-
challenging task when an established reference standard does not tion in the context of nursing process.
exist. In this study such a standard would have been the actual A total of 1293 documentation items were collected from the 25
patient status and the care provided. The goal of the chart review forms. This number was reduced to 1048 when only the unique ones
analysis was to investigate whether the current paper-based were counted, indicating that about 23% of identical items were
documentation provided enough information on the nursing care given different labels. More than half of the items fell in the
provided to the patient as perceived by those who did not assessment category. About a quarter of the items did not fit into any
participate in the patient care, such as the reviewers in this study. care process categories thus grouped as ‘‘other’’. The most common
In this sense, the results of the chart review still hold value mode of data entry was free-text (59%) and Boolean (30%). Only 11%
although it was done without knowledge of the complete patient of the items were documented using pre-defined pick-lists.
story. The 1048 unique documentation items were mapped to the
Studies show that the documentation quality was improved by care component categories of the Clinical Care Classification (CCC)
establishing a clear documentation model that reflects the system. The coverage was somewhat unbalanced. For example,
nursing practice of an institution and by providing training on current documentation seemed less focused on psychological
performing documentation following the proposed model [7,9]. In aspects of nursing care. However, in general, the distribution of
addition to training, a computerized documentation system with the care component categories showed that the current docu-
an explicit documentation model can improve the bedside mentation covered complete aspects of nursing care represented
documentation quality, and also enable detailed auditing to by these categories.
identify areas that are frequently incomplete or inadequately The chart review analysis showed that the current documentation
documented. failed to deliver sufficient and accurate data to represent nursing
In spite of the narrow scope, we have gained some useful care. Two major problems leading to the failure were identified:
insights on how to configure a computerized bedside documenta- incomplete documentation of nursing care process (e.g., missing
tion system at PHS. However we will need to expand this analysis assessment data, missing goal statement, etc) and improper writing
by including more documentation forms and templates and by style that caused confusion in interpreting the documented data.
reviewing more patient charts to ensure the findings of this study The first step towards developing a useful documentation system
can be generalized across various health care domains. In is to understand the problems of an existing paper-based documen-
addition, the scoring scheme used in this study needs to be tation system. Through this limited scope analysis on the nursing
scrutinized further to minimize subjectivity and to maximize the documentation content, we gained a number of useful insights on
quality of the information that evaluation scores deliver. designing a documentation system at PHS. Some of the most relevant
We excluded the data type of ‘‘synthesizing patient status insights include the extent of redundancy in the documentation
progressing toward identified nursing goal’’ from the chart review content, areas where more structure needs to be introduced to
analysis because we were already aware of that this type of data capture the data on nursing practice more completely and accurately,
was poorly documented. We were able to confirm this problem in and multiple design considerations for supporting the capture and
this chart review: we did not observe any ‘‘synthesis’’ information display of critical data for providing nursing care.
H. Kim et al. / Computers in Biology and Medicine 41 (2011) 182–189 189
Conflict of interest statement [7] M.R. Darmer, L. Ankersen, B.G. Nielsen, G. Landberger, E. Lippert, I. Egerod,
Nursing documentation audit—the effect of a VIPS implementation pro-
gramme in Denmark, J. Clin. Nurs. 15 (5) (2006) 525–534.
None declared. [8] M. Muller-Staub, M. Lunney, M.A. Lavin, I. Needham, M. Odenbreit, T. van
Achterberg, Testing the Q-DIO as an instrument to measure the documented
quality of nursing diagnoses, interventions, and outcomes, Int. J. Nurs.
References Terminol. Classif. 19 (1) (2008) 20–27.
[9] Gv Krogh, D. Naden, A nursing specific model of EPR documentation:
organizational and professional requirements, J. Nurs. Scholarship 20 (1)
[1] E. Ammenwerth, U. Mansmann, C. Iller, R. Eichstadter, Factors affecting and (2008) 68–75.
affected by user acceptance of computer-based nursing documentation: [10] V.K. Saba, The clinical care classification, March 10, 2009. Available from
results of a two-year study, J. Am. Med. Inform. Assoc. 10 (1) (2003) 69–84. /http://www.sabacare.comS.
[2] C. DesRoches, K. Donelan, P. Buerhaus, L. Zhonghe, Registered nurses’ use of [11] J. Bellack, B. Edlund, in: Nursing assessment and diagnosis, 2nd ed, Jones &
electronic health records: findings from a national survey, Medscape. J. Med. Barlett, 1992.
10 (7) (2008) 164. [12] National Quality Forum, March 8, 2009. Available from: /http://www.
[3] B. Gugerty, M.J. Maranda, M. Beachley, V.B. Navarro, S. Newbold, W. Hawk, qualityforum.org/S.
et al., in: Challenges and Opportunities in Documentation of the Nursing Care [13] C. Bjorvell, R. Wredling, I. Thorell-Ekstrand, Prerequisites and consequences
of Patients, Maryland Nursing Workflorce Commission, Baltimore, 2007. of nursing documentation in patient records as perceived by a group of
[4] K. Smith, V. Smith, M. Krugman, K. Oman, Evaluating the impact of computerized Registered Nurses, J. Clin. Nurs. 12 (2) (2003) 206–214.
clinical documentation, Comput. Inform. Nurs. 23 (3) (2005) 132–138. [14] S. Middleton, J. Lumby, Exploring the precursors of outcome evaluation in
[5] K. Irving, M. Treacy, A. Scott, A. Hyde, M. Butler, P. MacNeela, Discursive practices Australia: linking structure, process and outcome by peer review, Int. J. Nurs.
in the documentation of patient assessments, J. Adv. Nurs. 53 (2) (2006) 151–159. Pract. 4 (3) (1998) 151–155.
[6] K.G. Ferrell, Documentation, part 2: the best evidence of care. Complete and [15] Q. Zeng, J.J. Cimino, K.H. Zou, Providing concept-oriented views for clinical
accurate charting can be crucial to exonerating nurses in civil lawsuits, Am. J. data using a knowledge-based system: an evaluation, J. Am. Med. Inform.
Nurs. 107 (7) (2007) 61–64. Assoc. 9 (3) (2002) 294–305.
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