Clinician and Health Care Leaders' Experiences with—and Perceptions of—COVID-19 Documentation Reduction Policies and Practices

Moy, Amanda J.; Schwartz, James H.; Withall, Jennifer; Lucas, Eugene; Cato, Kenrick; Rosenbloom, S. Trent; Johnson, Kevin B.; Murphy, Judy; Detmer, Don E.; Rossetti, Sarah Collins

doi:10.1055/s-0041-1739518

Cited by 8 publications

(23 citation statements)

References 19 publications

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“…The fourth session was titled “Emerging and Future Innovations as Solutions.” The panels in this session focused on the job of documentation in the future, a discussion by industry members on the solutions coming out of industry, and the review of the COVID-19 survey. 20…”

Section: Methodsmentioning

confidence: 99%

“…18 These observations illustrate the large amount of clinical time given to documentation which has direct impact on workflow. 19 20…”

Section: Background and Significancementioning

confidence: 99%

“…18 These observations illustrate the large amount of clinical time given to documentation which has direct impact on workflow. 19,20 Many strategies that have been proposed for reducing documentation burden have their limitations in scope and potential impact. For example, solutions that delegate documentation tasks from clinicians to other entities such as, scribes or voice recognition software have developed into workarounds rather than lasting solutions.…”

Section: Background and Significancementioning

confidence: 99%

“…The panels in this session focused on the job of documentation in the future, a discussion by industry members on the solutions coming out of industry, and the review of the COVID-19 survey. 20 With the goal of eliciting collective stakeholder participation in developing consensus-based action items rather than differences in opinions, the final two sessions of the Symposium were organized as breakout groups. Over 100 participants selected breakout group topics organized according to the 2020 American Nursing Informatics Association (ANIA) Burden of EHR documentation conceptual framework.…”

Section: Symposium Eventsmentioning

confidence: 99%

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25 × 5 Symposium to Reduce Documentation Burden: Report-out and Call for Action

et al. 2022

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Background The widespread adoption of electronic health records and a simultaneous increase in regulatory demands have led to an acceleration of documentation requirements among clinicians. The corresponding burden from documentation requirements is a central contributor to clinician burnout and can lead to an increased risk of suboptimal patient care. Objective To address the problem of documentation burden, the 25 by 5: Symposium to Reduce Documentation Burden on United States Clinicians by 75% by 2025 (Symposium) was organized to provide a forum for experts to discuss the current state of documentation burden and to identify specific actions aimed at dramatically reducing documentation burden for clinicians. Methods The Symposium consisted of six weekly sessions with 33 presentations. The first four sessions included panel presentations discussing the challenges related to documentation burden. The final two sessions consisted of breakout groups aimed at engaging attendees in establishing interventions for reducing clinical documentation burden. Steering Committee members analyzed notes from each breakout group to develop a list of action items. Results The Steering Committee synthesized and prioritized 82 action items into Calls to Action among three stakeholder groups: Providers and Health Systems, Vendors, and Policy and Advocacy Groups. Action items were then categorized into as short-, medium-, or long-term goals. Themes that emerged from the breakout groups' notes include the following: accountability, evidence is critical, education and training, innovation of technology, and other miscellaneous goals (e.g., vendors will improve shared knowledge databases). Conclusion The Symposium successfully generated a list of interventions for short-, medium-, and long-term timeframes as a launching point to address documentation burden in explicit action-oriented ways. Addressing interventions to reduce undue documentation burden placed on clinicians will necessitate collaboration among all stakeholders.

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Section: Methodsmentioning

confidence: 99%

“…18 These observations illustrate the large amount of clinical time given to documentation which has direct impact on workflow. 19 20…”

Section: Background and Significancementioning

confidence: 99%

Section: Background and Significancementioning

confidence: 99%

Section: Symposium Eventsmentioning

confidence: 99%

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25 × 5 Symposium to Reduce Documentation Burden: Report-out and Call for Action

et al. 2022

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“…For example, there was an urgent need for language interpretation services, especially Spanish language interpreters, related to the high incidence of COVID‐19 in Spanish‐speaking communities (Samuels‐Kalow et al., 2021). Additionally, multiple strategies were employed to adapt preexisting nursing documentation standards for electronic health record system (EHR) charting to decrease data collection burden and expedite care delivery (Moy et al., 2021). As a result, standard nursing admission templates were temporarily replaced with shortened assessment forms, many with predetermined, highly structured response choices to refocus the types of data collected to address immediate concerns related to COVID‐19.…”

Section: Introductionmentioning

confidence: 99%

Nurse‐sensitive indicators during COVID‐19

Banister

Carroll

Dickins

et al. 2022

Int J of Nursing Knowl

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Purpose: Nurses are on the forefront of delivering care to patients hospitalized with COVID-19. Nurses' impact on patient care can be discerned through assessment and documentation strategies, including structured and unstructured narratives, clinical pathways, flowsheets, and problem-based approaches. To date, there are no published reports regarding nursing assessment and documentation during the COVID-19 pandemic using an assessment framework to capture clinical decision making, nursing diagnoses, and key social determinant of health (SDoH) data. Hence, the purpose of this investigation was to conduct an exploratory nursing documentation audit of patients hospitalized with COVID-19 during the first surge to identify types and frequency of nurse-sensitive indicators, including SDoH.Method: This pilot study utilized a retrospective chart review design at a single academic medical center, utilizing Gordon's Eleven Functional Health Patterns (FHP) framework to extract clinical, social, and nursing assessment data for patients hospitalized with COVID-19. Descriptive statistics were computed for continuous variables and counts/percentages for categorical variables.Findings: Data from 94 patient records were analyzed. Most patients were male (59.6%), with a mean age of 58 years. Nearly 15% of patients were Black and 12.8% were Hispanic, most residing in four geographic areas. Nine of the 11 FHPs were reflected in nursesensitive indicators documented in the electronic health record. SDoH data were inconsistently documented, including race, education, history of neglect/abuse, and occupation. Conclusion:The FHP framework captured many nurse-sensitive indicators during the first COVID-19 surge, although screening for and documenting SDoH data were limited.

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