Streamlining Documentation in the Electronic Medical Record

Purpose: To streamline electronic health record (EHR) documentation to increase efficiency and RN time management.

Background/significance: Historically, RNs spend much of their productive time documenting patient care and interactions. Depending on personal preference and situations, nursing notes can range from short focused to long and detailed. Additionally, variations in documentation compromise the healthcare team by impacting the readability of patient care notes. To provide efficient manual typing and remove variation, many EHR systems have built-in documentation tools also known as “smartpharses/smartlinks,” which auto-populate data and information into a note. “Smartphrases/smartlinks” may be independently developed or customized by the RN to utilize for many note types. Additionally, the “smartpharses/smartlinks” may be shared with other staff members within the EHR system. We discovered that poor use of “smartpharses/smartlinks” across ambulatory care areas resulted in RN spending a disproportionate amount of time between the patient encounter and the documentation of that encounter. Increased use of “smartpharses/smartlinks” will decrease documentation time and remove variation, thus improving efficiencies/productivity. On average, a person of moderate skill types 40 words per minute. The potential for increased RN productivity is substantial. 

Method: Baseline reports were created to measure the total manually typed character count and “smartpharses/smartlinks” utilization. Department RNs made “smartpharses/smartlinks” and agreed to utilize them for their standard most-used note types. To monitor progress, reports are reviewed monthly, anticipating increased “smartpharses/smartlinks” usage and decreased manual typing. 

Results: After one month (April 2020), the pilot clinic resulted in a 2% increase in “smartpharses/smartlinks” and a decrease in manually typed characters of 5.35%., resulting in a reduction of manual character count by 100,842 characters. 

Conclusion: This process is now in five subspecialty clinics, and the preliminary results are encouraging. A full quarter of data will be needed to determine the actual impact.