Healthcare documentation may take time away from care

Transparency and documentation are more important to healthcare than ever before, but an opinion piece in The New York Times argues that the healthcare industry may over emphasize paperwork at the expense of improving care quality.

Healthcare workers and clinicians are increasingly assessed based on how they document care rather than the outcomes of that care, writes registered nurse Theresa Brown. For example, she writes, when her hospital transitioned to bar-code scanning for medication administration, the hospital rated nurses based on the percentage of medication scanned and publicly displayed their ratings.

Similarly, hospitals task nurses with assessing a patient's risk of falls based on a combination of medication, mobility issues and confusion levels--a process, Brown writes, that takes time that could be better spent actually intervening to prevent patient falls. After all, while it may help clinicians prepare to know the patient may be a fall risk, simply knowing it does nothing to prevent it.

"All the attention given to our paperwork is taking us further and further away from the difficult truth that meeting very ill patients' needs occurs in real time with real people, not in the paperwork about them," Brown writes.

Indeed, evidence suggests that as important as documentation is, it can create inaccurate impressions of care quality. For example, much of what appears to be substantial progress in reducing preventable readmissions correlates with a steep increase in patients placed under observation status, FierceHealthcare previously reported.

To learn more:
- read the opinion piece

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