LONDON, UK, December 13, 2017 - Nurses must be involved in the development of software and apps that are designed to ease the burden of frontline nursing, including the challenge of completing clinical documentation, according to a panel of nurses and nurse leaders.
An array of technologies is currently shaping the production of clinical documentation. These include: apps that capture therapeutic observations and feed into the patient record; biometrics for identification and authentication of individuals; the power of the cloud for capture, access to and sharing of data; the use of speech recognition as a user interface and the prospect of digital assistants.
The panel of nurses and nurse leaders took part in a roundtable discussion on the clinical documentation challenge. Documentation is complex, laborious to complete, not always shared amongst the right teams, sometimes ignored and does not always contribute to improved clinical outcomes and patient safety. In addition, the journey towards a paperless NHS, with various attempts to digitise the clinical documentation process has led to a ‘digital mountain of documentation’.
With so much time being taken up on documentation2, there is inevitably an impact on face-to-face nursing. More time spent dealing with documentation and systems, means less time spent with patients.
The roundtable discussion, chaired by Anne Cooper, chief nurse, NHS Digital, resolved that creative technologists from leading digital technology companies could shadow the nursing fraternity and help them re-imagine clinical documentation. However, the technology must support the nurse, not the other way around.
There was also agreement that the clinical documentation challenge is not specific to nursing and should be considered as a system-wide issue. However, by bringing together frontline nurses from the acute, primary and mental health sectors it is clear there are unique aspects of nursing documentation that need to be addressed.
Anne Cooper said: “We are in a watershed moment where we rely increasingly on electronic patient records and if we don’t get some of the fundamentals right, then the risk is we will build on sand. We need to reflect the reality of what is happening in practice. Technology can enable a different way of working, but it has to be the right technology and nurses have to say what they need.”
Dr Simon Wallace, chief clinical information officer, Nuance, said: “Our aim in bringing together nurse leaders and frontline nurses was to look at ways we can overcome the documentation challenges they face every day. We found that although this is a system wide, one way we could address the challenges for nurses is by involving them early on in the development process.”
A detailed report which discusses the themes raise in the roundtable discussion and makes some key recommendations is now available here
In a 2016 @WeNurses tweetchat poll found 73 per cent of respondents said they went home late (171 responses) because of clinical documentation and 33 per cent of nurses said clinical documentation takes 20 to 40 per cent of their time.
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