29/05/2012 - Reducing Unnecessary Documentation

#NurChat to discuss “Reducing Unnecessary Documentation” – 29/5/2012 at 8pm

Nursing assessments, care plans, risk assessments and daily notes are just a small snapshot of the amount of documentation that nurses need to complete for each and every patient seen.  A recent Nursing Times article (Ward staffing pressures leave vital care undone) identified that often the development of care plans was being left undone at the end of their shift the article identified this as being due to decreased staffing levels – but what about the sheer amount of documentation, is this an issue too ?  As students we are taught that documentation is an essential part of the nursing process – Assess, Plan, Implement, Evaluate – each stage requiring its own relevant documentation, but is the volume of paperwork that we now have really needed?

Do we need to start to question some of the paperwork we are required to fill out? Which parts of documentation are essential? How do we ascertain what is merely a tick box exercise and what is essential? How can we cut back on paperwork in order to spend more time at the bedside?  What strategies can we employ to ensure that necessary documentation doesn’t have a detrimental impact but enhances patient care? 


Thanks goes to @eileenshepherd for this great suggestion


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Below are some links you may find useful to read before the chat

Ward staffing pressures leave vital care undone - Nursing Times

Documentation and record keeping - RCN

Record Keeping Guidance for nurses and midwives - NMC

Summary by Teresa Chinn RN
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Post Chat Summary 

This chat kicked off very quickly by NurChatters talking about the RCN record keeping guidance and how it is very good but there is no mention of digital record keeping and it was generally  agreed that regardless of medium the same rules apply but nurses need to be confident electronic records are fit for purpose.

It was then raised that standardised documentation should be implemented throughout the NHS –some added why just keep it to the NHS, but others debated that we do niot have a one size fits all approach in nursing so this may not work.

NurChatters brought up the issue of who completes the documentation and it was raised that more documentation should be completed by HCAs.  There were some concerns that HCAs would not have time for this but many NurChatters agreed that care should be documented by the individual who carries out the care.  It became obvious that many nurses stay on past the end of their shift to complete paperwork.  

NurChat asked how participants felt about patient held records and it was discussed that midwifery patients have carried their own notes for a long time and it is very successful.  However NurChatters put this down to the midwifery patients often being young and capable and it may not be appropriate for frail elderly or prisoners or those with some MH issues to carry their own records.  

The use of tablets was raised and it was felt that these would be good bedside devices for recording care as it happened in addition to being a useful resource if wifi enabled.  

NurChat then asked “Will digital records reduce the need for duplication of info? Will this help release time to care?”  It was generally agreed that yes digital documentation should vastly reduce repetition.

The importance of good record keeping was then raised and that it is sometimesonly when you see poor documentation, perhaps during a court hearing, that you realisethe importance.  NurChatters advocated going to observe an NMC hearing as a good way of learning about the importance of record keeping.

To conclude NurChat asked “Can we reduce time spent documenting? Or is it time well spent ?”

@timcoupland replied “Mainly time well spent, but systems do need refining, GP systems do seem better”

@TaskerKaren said “Meaningful doc is time well spent, if it means I (any nurse) can come care for your patient when you go home”

@michellemellor3 added “Agree – reliable and accurate doc just as imp as care delivery to maintain continuity”

@TaskerKaren “We should be proud to document the excellent care we have given to a patient, it’s not an afterthought or extra”

Summary by Teresa Chinn RN

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Chat Transcript (via Storify)

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