Creating a National Standard for Nursing Documentation Thru the use of Essential Clinical Dataset

Reducing nursing documentation burden results in time back for patient care lending to a better patient and nursing experience along with improved clinical outcomes. Across the nation, nurses complain they spend too much time documenting and therefore less time with their patients. As a call for action, national CNO’s asked for a resolution that would provide a national standardized nursing documentation standard. Cerner nurses rose to the challenge and in conjunction with many of our clients created the essential clinical dataset (ECD). In 2016, a national collaborative was formed with a specific lens on creating efficiencies in nursing documentation. As the collaborative met, they worked through the documentation elements that were to be considered for inclusion and exclusion in the new simplified documentation tool. The collaborative also included regulatory oversight across all decisions during the creation.
Data from over 48 individual ECD’s was collected and studied for elements such as nursing time in the electronic medical record (EMR), number of clicks and percentage of the data elements charted on. On just the adult admission history ECD we were able to save our clients over 35,000 hours and 12 plus million clicks! Cerner nurses listened to our fellow nurses caring for patients at the bedside and went into action to decrease their documentation burden.