Nursing Praxis for Reducing Documentation Burden Within Nursing Admission Assessments

Abstract

The purpose of this quality improvement project was to conduct a scholarly assessment of the information collected within the nursing admission encounter and implement content revisions across three pilot medical surgical units. The guiding principles were to preserve regulatory information, identify nurse-sensitive data, and eliminate nonessential information. The goal was to decrease the number of clicks and time expended to document electronically an acute admission encounter by 20% and to project the number of hours returned to patient care as a result of decreasing computer clicks. A second goal was to quantify the projected costs of completing a nursing admission encounter. This quality improvement project leveraged nurse executive competencies to intersect the nursing process to develop a nursing documentation praxis. This author's praxis reduced nursing documentation burden in clicks by 29% and reduced time to document on an admission encounter by 34%. This restored the focus on nurse-patient interactions by returning 1016 hours per year to patient care activities, across three pilot units, as well as quantified the costs of completing a nursing admission assessment to utilize in future cost analysis of nursing tasks.

Nurses' harm prevention practices during admission of an older person to the hospital: A multi‐method qualitative study

“…An older person's admission to the hospital is a crucial point for nurses to identify important care needs and plan strategies to prevent patient harm during hospitalization. Nursing admission of any person to the hospital is instrumental for care planning, and subsequent multidisciplinary care delivery; however, there are important consequences for older people who are particularly vulnerable to preventable patient harm and increased length of hospital stay (Moon et al, 2021 ; Phillips & Baur, 2021 ). Nurses' harm prevention practices during the hospital admission process for older people warrant scrutiny due to its importance for patient safety.…”

“…Nurses' harm prevention practices during the hospital admission process for older people warrant scrutiny due to its importance for patient safety. However, admission of an older person to a hospital ward is associated with a significant workload and cognitive burden for nurses (Andrzejewski, 2020 ; Phillips & Baur, 2021 ; Strassner et al, 2020 ; Trovo et al, 2020 ). Hospitals lack clearly defined, easily implementable strategies to assist nurses with comprehensive harm prevention during the admission of older people to the hospital (Redley, Douglas, et al, 2022 ; Redley, Taylor, et al, 2022 ).…”

“…Admission to the hospital is a crucial point for nurses to identify a patient's care needs and plan strategies to prevent patient harm, yet research on this important nursing process is limited. During the admission process, nurses assess and familiarize themselves with a patient and their care partners using visual cues, interactions and by completing multiple assessments (Phillips & Baur, 2021 ; Redley & Raggatt, 2017 ). Information collected by nurses is used by the multidisciplinary healthcare team as the basis for hospital care (Phillips & Baur, 2021 ).…”

“…During the admission process, nurses assess and familiarize themselves with a patient and their care partners using visual cues, interactions and by completing multiple assessments (Phillips & Baur, 2021 ; Redley & Raggatt, 2017 ). Information collected by nurses is used by the multidisciplinary healthcare team as the basis for hospital care (Phillips & Baur, 2021 ). The outcome of the admission process should be a personalized care plan to meet individual health and personal care needs and keep the patient safe in the hospital.…”

“…Patient admission is a complex activity with an intense workload and high cognitive demand for nurses (Phillips & Baur, 2021 ; Trovo et al, 2020 ). Nurses must negotiate hundreds of recommendations from care guidelines, hospital policies and procedures, to integrate with individual risk profiles and personal preferences of patients (McGrath et al, 2017 ; Redley, Douglas, et al, 2022 ).…”