Development of a Tool to Assess and Optimize Flowsheets

Documentation is a written record produced by a clinician that includes the plan of care, the care provided to the patient throughout their shift, and the outcome of care. Documentation gives the care provider a foundation of information that can be used to determine outcomes as well as the patient's response to nursing interventions. Nursing documentation gives the clinician a reliable narrative of all occurrences for the duration that the patient is in their care. Documentation plays a large role in the clinician's workflow. Good documentation is essential for clear communication, accurately describing the patient's condition and history, and problem-solving during the diagnosis and treatment of patients, especially when a patient has a poor prognosis. Documentation is critical if there is ever a need to recall nursing care in a legal situation. While documentation is valuable, it can be frustrating and time consuming, particularly when the documentation templates are not up to current standards. Documentation that is subpar or incomplete can be burdensome, irrelevant, inaccurate and inefficient, which makes it unusable to the clinician. Decreasing documentation burden across healthcare settings is important because clinicians have high levels of documentation requirements within patient care settings (Collins et al., 2018). Clinical documentation is often underappreciated (Elkbuli et al., 2018). Poor or inadequate documentation may not accurately reflect actual harm or comorbidities and may impact accuracy of mortality measures (Elkbuli et al., 2018). Documentation has evolved from paper records to computerized records as electronic health records (EHR) have become more common. According to the Health IT Dashboard (2017), a s of 2015, over four in five of all non-federal acute care hospitals had adopted a Basic EHR with clinician notes. It is important to stop expect that EHRs will decrease documentation time, and instead begin to identify best practices for EHR documentation and optimization (MacCartney, 2013). Improving the EHR will allow for improved and complete documentation within the inpatient daily cares flowsheet for the health care aide and nurse.