Studies estimate that nurses spend as little as 15 percent of their time on direct patient care. As much as half goes to documentation
Documentation poses a tremendous, often unmanageable,
challenge and has become the root cause of many patient safety and other problems. Busy physicians and busy nurses might not remember or have time to read each other’s notes. Information entered by other healthcare professionals is seldom integrated into physician and/or nursing documentation. These silos of information by discipline do not lead to the best care plan.
Data generated by any one group that may be of interest to other groups should be integrated, easily accessible, and clearly visible as patient-centric information. Systematic data collection reduces paperwork redundancy and improves quality of care and fiscal efficiency. Single-entry data sets can save staff time by directly supporting reporting requirements that involve patient classification, acuity level, productivity, quality of care, decision support software and financial analysis.
Many healthcare organizations have begun incorporating evidence-based clinical knowledge, integrated clinical and financial information systems (ISs), and point-of-care technologies into various departments–capabilities that may have widespread effects on nursing roles.