Blog | Tuesday, October 4, 2016

Nursing documentation vs. patient care: Who's leading?

I work with nurses every day. Anyone who doesn't realize how hard these professionals work has never been in a hospital. Their job descriptions have expanded along with their work load. This is not your father's hospital ward. Hospitalized patients today are older and sicker than ever before. It takes a seasoned nursing professional to manage the care of these complex patients. Their work days are full simply managing the expected tasks of dispensing medications, coordinating diagnostic tests and assessing their patients. There is no time scheduled for unexpected events, which are expected as sick people's conditions may change at any moment. In other words, if a nurse must attend immediately to a patient with chest pain, then his or her other more mundane tasks are delayed or shifted over to another busy nurse.

I believe that the most potent barrier that is separating nurses from their patients today is the ferocious documentation mandates that nurses are required to perform. The hospital corridors are clogged with nurses hovering over computers entering all kinds of data, most of which will never be viewed by physicians. These nurses are not techies who want to be palpating a keyboard. They are compassionate caregivers who want to be in their patients' rooms caring for them.

If you suspect that I am exaggerating here, then go ask a nurse.

Moreover, the hospital's electronic medical record system has become deeply layered and complex. Often I can't find the specific data I need. Just last week, a couple of senior nurses and I were scouring through the computer to find a patient's result of stool testing for blood. We simply couldn't find it, and these nurses are pros. At that point we were left with the following options:
• Reorder the test;
• Make up the result;
• Quit the profession and become an Uber driver;
• Ask the patient what the result was; or
• Hire a 12-year-old who could find the results in a few seconds.

While the computer record is packed with data concerning every aspect of the patient's medical experience, I have my own approach to find out what's going on. Pay close attention here. Read the next sentence very slowly as I want readers to grasp the complex process I use each day as I approach the nurse.

“Hi. What's going on with my patient?”

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.