“If it is not documented, then it is not done.” This expression is one that is commonly known amongst nurses working in direct care roles. Beyond this expression, is a need to recognize the value that documentation provides in care delivery.

As a nurse and/or healthcare professional, the responsibility one has is to provide the highest quality care. To do so requires accurate and accessible data and information about the patient.

Data and information about the patient needs to be entered into the record. That data and information must also be retrievable for effective use.

Two weeks ago, AMIA (American Medical Informatics Association) released results from a survey, TrendBurden, taken during the month of April 2024 with over 1200 respondents. In addition to nurses, physicians, social workers, educators, and other healthcare professionals participated in the survey. Details of the survey questions can be found at the above link. The responses were reported on a 3 point likert scale (Agree/Strongly Agree, Neither Agree nor Disagree, Disagree/Strongly Disagree).

Documentation burden may be seen initially as a health information technology issue. However, there are larger implications for the workforce. The questions asked in the survey include:

1. The amount of time and effort I spend documenting patient care is appropriate. The majority disagreed that the necessary time to document patient care was appropriate.
2. I finish work later than desired or need to do work at home because of excessive documentation tasks. The majority agreed that they work later or do work at home because of documentation needs.
3. Recently, there has been a noticeable decrease in the time or effort or both needed for me to complete my documentation tasks. The majority disagreed that there has been a noticeable decrease to complete documentation.
4. The effort or time required for me to complete documentation tasks impedes patient care. The majority agreed that documentation time or effort impedes patient care.
5. I find it easy to document patient care using the electronic health record. The majority of physicians disagreed that documentation is easy while nurses’ responses were split between agree (38%) and disagree (38.5%).

Surveys are self-reported data from the users. Having their voices heard in this manner opens the door for exploration into finding ways to address these documentation burdens that continue to persist.

It takes years to become a healthcare professional and even more years to become an experienced to expert care provider. Those years cannot easily be replaced. However, technology can be created to support the workflows and the people who use them and disseminate those at scale.

I would encourage you to explore the responses for yourself here. The responses are broken into three categories of responses: All, Physicians, and Nurses. What I appreciate about this particular survey is the side by side comparison of responses between nurses and physicians (and then an aggregate).

~ Dr. Kelley

Tiffany Kelley PhD MBA RN NI-BC FNAP