As healthcare organizations continue to leverage Electronic Medical Records (EMR) software solutions, there are concerns about an increase in physician burden related to documentation. Clinical documentation pressure on acute care nurses is increasing which can impact patient care. Recently, nurses were unhappy about time-consuming clinical documentation at UCHealth. This encouraged the hospital system for an Epic EHR optimization to cut clinical documentation time to enhance user satisfaction and reduce any chances of burnout associated with tedious documentation. The reports feature tool in the Epic Electronic Health Records Software showed that acute care nurses were spending more than 30% navigating the EHR software system of every 12-hour shift.
Reviewing of Documentation Tools
A task force was created to evaluate the documentation tools used most often by acute care nurses at UCHealth. The documentation requirements were closely assessed by nurse managers and nurse teams. In the documentation tools only the data that met the following benchmarks were kept, these included;
- Required to offer patient care.
- The nurse can document it solely.
- A flowsheet is the only way to enter data.
- Populates a critical report or a patient header.
- It is essential for billing.
- Used to document when a patient declined care offered to them.
The aim was to enhance documentation workflows by redesigning flowsheets by removing rows and values that are irrelevant to the patient. These changes made in the flowsheets resulted in an 18 minutes decline in the documentation time spent by each nurse every 12-hour shift. This accounted for over 46,000 hours saved yearly.
Benefits of Enhanced Documentation
Improved clinical documentation can lead to streamlined workflows, enhanced user satisfaction, and better time management to offer patient-centered care and enhance overall work-life balance. The screens and workflows offered by Epic EMR Software are user-friendly and flexible enough to be customized according to specific needs. The Epic SmartTools functionality can be used to automate tedious documentation tasks so nurses and physicians can concentrate on patient care and enhance patient outcome levels.
