Streamlining Inpatient Nurse Documentation
In 2023 , Children ’ s Colorado launched a project aimed at reducing the burden of documentation on inpatient nurses . This crucial work was initiated in response to feedback from nurses that their ability to deliver the highest quality patient-centered care would be enhanced if they were able to reduce the time they spend charting .
Driven by a dedicated multidisciplinary workgroup comprised of bedside nurses and respiratory therapists , this project redefined the criteria for required documentation in alignment with industry best practices . It also established guiding principles for future practices while ensuring documentation standards remain in compliance with all regulatory , quality and safety requirements .
At the project ’ s outset , the team established baseline data to gauge the quantity of documentation within the system . These data revealed a high volume of daily input across various flowsheets . A flowsheet cleanup committee began convening biweekly in April 2023 , meticulously reviewing each flowsheet line by line . Through the end of 2023 , the team had scrutinized a total of 6,213 line items across 63 flowsheets . This endeavor has been substantial , demanding collaborative discussions to collectively make informed decisions and ensure all documentation directly contributes to valuable patient care .
This process helped the team discover numerous instances of documentation that no longer serve a purpose . These had become habitual in practice but lacked meaningful value in clinical care . Identifying such redundancies has been a pivotal step in efforts to refine and focus on documentation that genuinely enhances the standard of care .
The first phase of implementation in August 2023 focused on streamlining and minimizing documentation for the pediatric intensive care unit , cardiac intensive care unit and neonatal intensive care unit nursing shift assessments . The team achieved a notable 70-90 % reduction in the total number of required rows of documentation . Approximately 10 % of these rows were completely retired , as they were deemed no longer necessary ; another 10 % were removed from shift flowsheets but retained in other sections of the medical record .
The project ’ s second phase of implementation launched in November 2023 , encompassing comprehensive updates to all body assessment documentation . This pivotal step signifies a transition to a document by exception methodology . Essentially , this approach entails documenting only deviations from established norms , eliminating routine recording of normal assessment values in alignment with industry best practices . As part of this implementation , the team also revised assessment language to promote inclusivity , moving away from terminologies that might not comprehensively assess skin health across diverse skin tones .
The documentation reduction team will continue to review and revise current practices while identifying additional opportunities to reduce the burden of documentation . This will ultimately give inpatient nurses and respiratory therapists more time at the bedside with their patients .
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2023 PCS Annual Report