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Keeping Patients Safe: Transforming the Work Environment of Nurses
rather than on documentation of normal findings (Blachly and Young, 1998; Murphy et al., 1988). Exception-based charting does not ignore normal findings; rather, it allows a notation (e.g., a check mark or caregiver initials) that care was provided in accordance with certain hospital-adopted standards of care, such as those found in clinical pathways. Narrative or more detailed notes are written when care and responses deviate from the expected:
For example, nurses formerly were asked to file an IV site check … every hour to “prove” that hourly checks were performed. Such documentation was mechanistic and was often entered all at once at the end of the shift. It did nothing to improve quality of care and provided no advantage. The new [charting by exception] approach allows the nurse to chart once, verifying the IV site was checked hourly … (LaDuke, 2001:285).
Exception-based charting is used more often in acute care settings than in long-term care (Blachly and Young, 1998). In both settings, it is associated with reducing the amount of time nurses spend in documenting care (Blachly and Young, 1998; Stephens and Mason, 1999; Wroblewski and Werrbach, 1999).
Some of the most effective strategies for achieving more-efficient documentation result from multidisciplinary documentation redesign initiatives (Brunt et al., 1999; Mosher et al., 1996; Smeltzer et al., 1996). For example, an interdisciplinary documentation work redesign and performance improvement initiative undertaken by Summa Health System in Akron, Ohio, found at baseline an excess number of forms, duplication of information throughout patient charts, poor use of data and information across disciplines, and large amounts of nursing time dedicated to patient care documentation. After a broad-based interdisciplinary initiative examining the processes and information flow needed to support interdisciplinary practice, Summa reengineered its patient care documentation processes.
Among the positive results of this initiative were the elimination of 80 forms; a decrease in multiple data entry (e.g., allergies were documented in 15 places prior to the redesign and in 2 places following the redesign; diagnoses were listed in 16 versus 4 places); and a decrease in the amount of time nurses spent in documentation from baseline survey reports of 25–40 percent to postimplementation survey reports of 10–20 percent. All these results were achieved by redesigning manual documentation processes; automated documentation was defined as a future goal (Brunt et al., 1999).
With regard to the use of automation, evidence exists that automated computer-based data entry, if carefully designed, can reduce the time required for documentation (Pabst et al., 1996), improve the quality of documentation (Nahm and Poston, 2000), or both. Some organizations have achieved cost savings as well (Baldwin, 1998; Weiss and Hailstone, 1993;