NR 500 Week 5 Duplicate Documentation Problem Brief Example

Practice Problem Brief: Vital Signs Entered Twice on a 32-Bed Medical Unit, Set Beside What Is Published About Nurses' Documentation Time

Student Name

College of Nursing, Chamberlain University

NR 500: Foundational Concepts and Applications

Instructor Name

Month Day, Year

Practice Problem Brief: Vital Signs Entered Twice on a 32-Bed Medical Unit, Set Beside What Is Published About Nurses' Documentation Time

The Problem, in One Sentence

On my 32-bed adult medical unit, nurses enter every set of vital signs twice, once in the flowsheet and again in a free-text shift note, because the note template does not pull the flowsheet values, and this double entry consumes time and produces records that sometimes disagree.

Enough About the Unit to Place It

The unit is an adult medical floor in a community hospital, staffed on day shift with six registered nurses for 32 beds and four hours of nursing assistant time per nurse. Most patients have vital signs taken every four hours, and those on the unit's early-warning protocol every two. The hospital moved to its current electronic health record five years ago. The shift note template was built at go-live, and nurses were told at the time to "summarize the vitals" in it. The instruction has never been removed, so nurses copy the latest numbers from the flowsheet into the note, often by memory, sometimes by retyping.

The Local Half

To make the problem concrete, I reviewed 20 shift notes from one week, with my manager's permission and with identifying information removed, and compared the vital signs typed into each note with the flowsheet values closest in time. In 7 of the 20 notes, at least one value in the note differed from the flowsheet: a heart rate of 88 typed as 83, a blood pressure from the previous set, a temperature rounded differently. None of these led to a wrong decision that I could find, but each is a place where a reader could. I also asked five nurses how long the vitals portion of the note takes them; their estimates ranged from 2 to 5 minutes per patient per shift. For a nurse with five patients, that is 10 to 25 minutes a shift spent retyping numbers the record already holds.

These are small samples, and nurses' time estimates are not measurements. The brief uses them to describe the problem, not to prove its size.

The Published Half

The published evidence frames the local picture in two ways. First, documentation takes a large share of nurses' time. Hendrich et al. (2008) followed 767 medical-surgical nurses in 36 hospitals with time and motion methods and reported that documentation accounted for 35.3% of nursing practice time, about 147 minutes of a shift, more than any other activity, against just 7.2% for assessing patients and taking vital signs. That study predates widespread electronic records in many hospitals, so its figures may not describe current practice, but it establishes documentation as a major use of nursing time.

Second, the burden is hard to measure well. Moy et al. (2021), reviewing 35 studies of documentation burden among physicians and nurses using electronic records, concluded that nobody yet agrees on how to measure it, and that validated instruments are missing. That finding matters for this brief: it means that a hospital wanting to show the effect of removing double entry will need to choose and define its own measure, and should say which one it chose.

Why the Problem Has Lasted Five Years

A problem this visible has survived for a reason, and the brief would be incomplete without it. No one owns the shift note template. It was built by the implementation team, which disbanded after go-live; the unit's educators assume it belongs to informatics, and the informatics team assumes the units would have asked for changes if they wanted them. Nurses, meanwhile, have absorbed the double entry into their routine and no longer notice it as a separate task, much as a detour becomes the route after enough time. When I asked colleagues why the vitals are in the note, the most common answer was "that's how we were taught."

There is also a quieter reason. Some nurses told me they like typing the vitals because it makes them look at the numbers once more before writing their summary, a kind of informal double check. That is a real benefit, and a redesign should keep it. A template that pulls the values automatically and then asks the nurse to confirm or comment on them would keep the second look while removing the retyping and the copying mistakes it invites.

What This Specialty Would Add

A bedside nurse can see the problem. What the informatics specialty adds is the ability to change the tool and to measure the change. An informatics nurse could redesign the shift note template so that it pulls the most recent vital signs automatically, remove the outdated instruction to summarize them, and test the change with nurses before it goes live. The same nurse could define the measure in advance, such as the proportion of notes with values that disagree with the flowsheet, and time spent in the note from audit data where the record provides it, and compare before and after. That combination of clinical knowledge, system knowledge and measurement is the specialty's particular contribution.

What Is Not Known

Three things are not known. How often, if ever, a disagreement between note and flowsheet has changed a clinical decision on this unit; my review found none, but 20 notes is too few to rule it out. How much time the double entry actually takes, as opposed to nurses' estimates; the record's audit data might answer this, but I have not had access to it. And whether nurses read the vital signs in the note at all, or go straight to the flowsheet; if no one reads them, the case for removing them is stronger still. Each of these is a question the redesign project would answer as part of its measurement, rather than an assumption the brief can make now.

The Size of the Ask

The change this brief points toward is small by informatics standards: a template edit, a short test with nurses on one unit, a one-page education note, and a before-and-after measure. It does not require new software or a vendor contract change. That matters for whether it will happen, because problems with small, owned solutions are far more likely to be fixed than problems that need a committee. The brief's recommendation is therefore modest and specific: assign the shift note template an owner, pilot the automated vitals pull on this unit for one month, and measure disagreement and time as defined above.

References

Hendrich, A., Chow, M. P., Skierczynski, B. A., & Lu, Z. (2008). A 36-hospital time and motion study: How do medical-surgical nurses spend their time? The Permanente Journal, 12(3), 25-34. https://doi.org/10.7812/TPP/08-021

Moy, A. J., Schwartz, J. M., Chen, R., Sadri, S., Lucas, E., Cato, K. D., & Rossetti, S. C. (2021). Measurement of clinical documentation burden among physicians and nurses using electronic health records: A scoping review. Journal of the American Medical Informatics Association, 28(5), 998-1008. https://doi.org/10.1093/jamia/ocaa325