Less Is More: Improving Quality and Safety Through Streamlined Electronic Health Record Documentation

6 minutes

Recurring waves of COVID infections have added significant stress to the healthcare workforce. Many caregivers are leaving the hospital in favor of higher paying “traveler” positions or have left the profession altogether. Hospitals now have more patients being cared for by fewer, more expensive, and less experienced clinical associates.

Now is an ideal time to take meaningful steps to ease the care provider’s burden—starting with excess electronic health record (EHR) documentation.

A complete EHR overhaul can take years; however, there are several “quick hits” that your hospital can take to streamline documentation while increasing quality, safety, communication, compliance, and caregiver satisfaction. A good start would be to remove 70% to 80% of the “clicks” in nursing assessments, reassessments, and care notes.

Every unnecessary EHR entry robs the caregiver of time caring for their patient and submerges essential clinical details under a sea of meaningless and, oftentimes, inaccurate information.

Pay attention to the following as you begin your journey to uncluttered documentation.

1. Dispel the Myth That Excess Documentation Is Required by Regulations or Standards

Contrary to popular belief, very few elements of documentation are required by regulations or standards. They include:

  • CMS requires an admitting history and physical examination (H&P), but regulations and standards do not indicate exactly what should be captured in the H&P. It’s up to the hospital.
  • The Joint Commission (TJC) requires a written plan for care and treatment for each inpatient, but it does not specify the format and content of this plan.
  • TJC requires a pre-sedation assessment but does not specify the elements of the assessment note (e.g., airway).

Typical regulatory requirements address a process that must be in place rather than the documentation. The process is expected to comply with applicable requirements and incorporate evidence-based standards of care/service, but EHR documentation is only required to the extent that it is necessary to support the process.

Steer Clear of “Documentation Creep”

Many meaningless and mythically “required” elements of documentation creep into the medical record. These elements are based on dim or secondhand recollections of offhand surveyor comments, inaccurate citations received previously, the way they do it “in the hospital down the road,” or they’re based on inaccurate or unclear regulatory interpretations by lecturers or agency representatives. The following are two examples.

  • Hospitals are required to ensure that caregivers refer cases to law enforcement when an individual is suspected of being a victim of abuse or neglect; however, there is no requirement that the abuse/neglect screening process be documented in the medical record. The standards only require that any indicated referrals to law enforcement be captured in the EHR. And most hospitals have checkboxes in the medical record documenting abuse and neglect screening, which is neither required nor advised.
  • Bedside nurses are often asked to document an endless stream of patient safety activities: “side rails are up,” “the patient is turned to their left side,” “the call bell is within reach,” to name a few. Interestingly, none of this documentation is required, and it does not result in raising a single side rail, turning a patient, or assuring that a call bell is handy. It only places the hospital at risk when evaluators inevitably find that the situation documented does not match the situation observed.

Regulatory agencies (state departments of health, CMS, etc.) and accreditors (TJC and others) are delighted when organizations follow expert guidance and substantially reduce nursing/ancillary documentation.

Although most hospitals address clinical survey findings by compounding the documentation burden, all regulatory agencies and accreditors intend just the opposite.

Help Me Understand

The regulations and the surveyors that enforce streamlined guidance find that increasing the number of clicks and menu selections is the opposite of compliance. Documentation overkill generally means less compliance and more regulatory vulnerability.

Surveyors and survey agencies agree that optimizing communication and outcomes through streamlined, less cluttered documentation results in better regulatory compliance while enhancing patient safety and satisfying physicians, nurses, and ancillary caregivers.

So, the next time someone insists on adding or keeping an element of documentation only because it’s “required,” gently ask them to show you the actual requirement, kindly say “Help me understand,” and take the language of the requirement at face value.

Remember: the purpose of the medical record is NOT to prove something happened. The purpose of the EHR is to support the process of care and communicate among the healthcare team. Avoid “prove it happened” documentation unless it is specifically required.

2. Avoid Overengineered Assessments

The elusive quest for “best practice” accounts for almost as much documentation overkill as regulatory myth. Subject matter experts oftentimes advocate for state-of-the-art documentation, which tends to be overkill for the purpose of a nursing assessment. It’s not uncommon to see nursing assessments with 20-question nutritional screens designed by expert dietitians, complex skin assessments designed by skin integrity specialists, and multi-factorial discharge planning assessments advocated by case management. Yet the role of nursing for these and similar subjects is to screen and refer. The ancillary discipline has the responsibility to fully assess referred patients. The bedside nurse should only collect and document enough information to determine when a referral to a subject matter expert is indicated. Detailed ancillary assessments should be left to SMEs. So:

  • Should there be triggers for referrals to case management, nutritional care, and others? Yes.
  • Should those triggers grow into a full-blown nursing assessment that would best be conducted by the ancillary discipline? Absolutely not.

3. Don’t Fall Into the Defensive Documentation Trap

You’ve heard the old and persistent myth, “If it wasn’t documented it wasn’t done.” This is untrue. It’s a harmful aphorism that stems primarily from professional liability (malpractice) cases.

The actual Risk Management vulnerability is that if documentation is required by the hospital and is not entered in the medical record, then the hospital has failed to fulfill its duty to the patient (a duty it created), and the hospital or the nurse might be at slightly more risk to be found liable.

Current thinking is that every nonrequired or non-value-added element of documentation increases the hospital’s professional liability risk.

It’s common to hear, “How can I know that something was done if it was not documented?” But let’s get real: documenting that a nurse conducted an hourly round or that a patient was “offered toileting” does not help the nurse actually perform patient safety rounds. Taking the time to document such things robs the nurse or ancillary staff member of time better spent performing the documented activity.

Ask anyone at the bedside and, if they are being forthcoming, they will likely agree that there is only a tenuous connection between the nursing tasks documented and the nursing care provided.

The Time Is Now

Now, more than ever, organizations must make a caregiver’s duties easier to fulfill by creating less busy work and maximizing the professional skills of their highly trained associates.

Streamlining documentation requirements is a good place to start.

© 2023 Chartis Clinical Quality Solutions. All rights reserved. This content draws on the research and experience of Chartis consultants and other sources. It is for general information purposes only and should not be used as a substitute for consultation with professional advisors. It does not constitute legal advice.

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