Nursing documentation is a vital component of comprehensive patient care and makes a significant contribution to the total patient record. Many documents are used to record, inform and influence clinical decision making throughout the patient stay.

While collecting this data is vital, the admission documentation process poses a significant administrative burden to staff on the ward in terms of time and concentration. An audit carried out with the Trust Project Management Department identified approximately 4200 patients admitted annually to the pilot ward. A time in motion study was used to calculate the time spent generating admission paperwork and this totalled 2485 hours annually based on an average of 35.5 minutes recorded per episode. Annually this represented 1.4 full time members of staff used to clerk patients based on a working time equivalent of 1800 hours per annum. On average the admission pack comprised 18 documents requiring data duplication alone on 151 separate episodes. Moreover, with increasing litigation, rising insurance costs and a government focus on patient safety, nursing documentation had recently expanded exponentially requiring more administrative time than ever

A software application to automate admission casenote preparation, improving the quality and consistency of casenotes and release nursing time to care. The application will help ensure all patients have a wristband on admission by utilitising the NHS Number barcode on the wristband to start the process of automatic casenote preparation. Enable recovery of patient demographics using the current EPR system thus avoiding data entry errors, ensuring all documents are completed to the correct level and generated successfully. Further options are to include equipment / asset allocation and bed availability where required.

Pre-Implementation completeness of short stay clinical records: full compliance was achieved twice out of six clinical records. Post-Implementation 100% compliance was achieved across all six records. Long stay clinical records reached 100% compliance across all ten records post-Implementation, pre-Implementation 100% compliance was reached across three clinical records.  Staff believed a significant improvement in the quality and speed of producing documentation and in terms of workload considerably better.  Total time saved in terms of nursing time per-annum was 1100 hours or 0.7 Working Time Equivalent. The nature of the I.T. system also required scanning patients’ wristband identifiers which revealed a significant reduction in non-compliance from 45% to 3%.  Automated case note production had released time to care on the ward and demonstrated a significant improvement in documentation compliance.  Quality and safety had also improved with increased use of patient wristbands and additional assessment documents included without any increase in the administration burden placed on nursing staff.