Computers in Biology and Medicine 41 (2011) 182–189

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Computers in Biology and Medicine

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A closer look at nursing documentation on paper forms: Preparation for

computerizing a nursing documentation system
Hyeoneui Kim a,n,1, Patricia C. Dykes b,2, Debra Thomas b,2, Linda A. Winfield b,2, Roberto A. Rocha b,2
a
Division of Biomedical Informatics, Department of Medicine, University of California, San Diego, 9500 Gilman Drive #0671, La Jolla, CA 92093-0671, USA
b
Clinical Informatics Research & Development, Partners Healthcare System, 93 Worcester Street, Wellesley, MA, USA

a r t i c l e in f o a b s t r a c t

Article history: A small scale documentation analysis was conducted to explore the medical and surgical nursing
Received 24 August 2009 content of the patient record at a large teaching hospital affiliated with Partners Healthcare System
Accepted 27 August 2010 (PHS), in preparation for a computerized documentation system. Through this study, we identified a
number of problems associated with the paper record that require resolution in the new computerized
Keywords: system, including elimination of documentation redundancy, areas where more structure is needed to
Nursing documentation properly capture data on nursing practice, and various design considerations to support a more
Content analysis complete and accurate documentation of nursing care.
Electronic documentation system & 2010 Elsevier Ltd. All rights reserved.

1. Introduction considered as a reflection of the quality of the care provided [5].

Ideally, an electronic health record (EHR) is capable of
improving many shortcomings of a paper-based documentation
system. However, related studies have reported mixed outcomes
[1–4]. Partners Healthcare System (PHS) is in the early stage of
implementing a computerized bedside documentation system.
We conducted a baseline analysis of the content of existing paper
documentation forms, in an effort to help us better understand
the potential barriers to documenting key nursing care informa-
tion in a reusable way in a computerized system.
The specific questions that we attempted to answer in this
study were: (1) what are the characteristics of the data that
nurses document?; (2) does the current nursing documentation
practice based on paper forms provide enough data to support the
entire spectrum of nursing care i.e., problem (nursing diagnosis)
identification, care planning, intervention, and outcome evalua-
tion?; (3) how is a ‘free-text’ field used and how well does it fulfill
the intended documentation purpose?
2. Background
Nursing documentation is the record of care planned and/or
provided to patients. The quality of the documentation is often
n
Corresponding author. Tel.: + 1 858 822 4368; fax: + 1 858 822 3344.
E-mail addresses: hyeoneui@ucsd.edu (H. Kim), pdykes@partners.org
(P.C. Dykes), dthomas@partners.org (D. Thomas), lwinfield@partners.org
(L.A. Winfield), rarocha@partners.org (R.A. Rocha).
1
Formerly with Clinical Informatics Research & Development, Partners
Healthcare System, Wellesley, MA.
2
Tel.: +1 781 416 9258; fax: +1 815 301 8228.
Nursing documentation serves various purposes, such as collect-
ing data on a patient’s health condition or illness for planning and
evaluating care; communication among health care professionals;
and providing evidence to legal issues [6]. Nurses spend up to 25%
of their time on documentation [3,5]. However, studies
have shown that the usefulness of nursing documentation in
planning and evaluating patient care activities remains unsatis-
factory [7–9].
In many PHS affiliated hospitals, the existing paper-based
process includes four key documentation forms that directly
guide the planning, providing, and evaluating activities of nursing
care. On admission, nurses assess patients and document the data
on the ‘‘admission assessment form’’. Based on the baseline data
obtained through the admission assessment, target nursing
problems (i.e., nursing diagnoses) are identified, expected care
outcomes (goals) are defined, and necessary interventions are
planned. These diagnoses, goals, and interventions are documen-
ted on the ‘‘plan of care form’’. The patient status related to a
nursing diagnosis is continuously re-assessed and documented
mostly on ‘‘flowsheets’’. Interventions provided for the diagnosis
are also documented mostly on ‘‘flowsheets’’. At the end of each
shift, nurses complete a ‘‘progress note’’ by synthesizing patient
status in progressing toward the pre-defined goals. The ‘‘plan of
care form’’ is updated every day, or with a change in patient
status. Fig. 1 illustrates the information flow among these
documentation forms.
As a patient is cared for by a team of nurses in many PHS
affiliated hospitals, admission assessment, care planning (i.e.,
identifying target nursing problems, nursing care goals and
intervention plans), continuous re-assessment, intervention and
synthesizing the progress toward goals are often done by different

0010-4825/$ - see front matter & 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.compbiomed.2010.08.006
 H. Kim et al. / Computers in Biology and Medicine 41 (2011) 182–189
Admission
Nursing
Assessment
Plan of Care
Admission Form
Nursing Flow sheets
Progress
Note
Fig. 1. Information flow among documentation forms.
nurses. While nurses also use verbal and/or tape recorded shift
reports to communicate important nursing care information,
documentation of complete and accurate information is needed to
reflect the entire spectrum of nursing care. Documentation of care
planned and provided is an important nursing responsibility
[6,7,9].
3. Methods
This study was conducted by reviewing a limited number of
medical and surgical nursing patient records in a PHS affiliated
teaching hospital. First, we analyzed the paper documentation
forms and templates that nurses use, in an effort to investigate the
nature of the data being captured by nurses. Second, we
conducted a small scale chart review to investigate: (a) how
completely current paper-based documentation practice supports
capturing the data required to provide nursing care and (b) the
usage of free-text fields on flowsheets.
3.1. Documentation forms
We collected 25 structured paper forms used by nurses in
medical or surgical inpatient units. These forms included assess-
ment and intervention flowsheets, admission assessment forms,
transfer reports, clinical event records, daily treatment sheets, and
special intervention records.
3.2. Clinical Care Classification (CCC) [10]
The CCC is a standardized nursing terminology designed to
encode the discrete elements of nursing practice in an EHR [10].
Its 21 care components cover four nursing care patterns; health
behavioral, functional, physiological, and psychological. The 21
care components represent unique and mutually exclusive
domains of nursing care that encompass the complete spectrum
of the nursing process; assessment, diagnosis, intervention, and
evaluation. Each component is further expanded to more granular
concepts thus identifying a relevant care component category.
This concept structure guides encoding detailed nursing data with
CCC. For example, a care component category ‘‘Skin Integrity’’ is
linked to the detailed concepts that can be used to encode
problems (i.e., nursing diagnoses) and interventions that are
related to skin integrity related conditions. Fig. 2 shows a part of
the CCC concept structure related to the skin integrity care
component category as an example.
We have selected the care component categories of the CCC to
produce an overview on the degree to which current state paper-
based documentation captures various nursing care domains
183
Care Component Category
Skin Integrity
Nursing Diagnosis Nursing Intervention
Oral Mucous Skin Incision Mouth Care Incision Care
Membrane
Impairment
Fig. 2. An example of the Clinical Care Classification system concept structure.
because they provide comprehensive and mutually exclusive
domain labels of nursing care. In addition, the CCC was being
reviewed by the informatics team at PHS for potential inclusion as
a nursing terminology reference source at the time of analysis
thus it provided a logical underpinning for this study.
3.3. Collecting documentation instances
We manually transcribed the documentation items contained
in the paper forms into a Microsoft Access database built for this
analysis. The format of the response entry of a documentation
item was captured using the categories of ‘‘free text,’’ ‘‘pick-list,’’
and ‘‘Boolean’’.
Many documentation items sharing the same meaning were
expressed using different terms. Therefore, an informatics trained
nurse assigned a ‘‘normalized expression’’ to each item to capture
its intended meaning and to subsequently identify synonymous
items. Four other nurses acting as reviewers later validated the
normalized expressions and assigned additional metadata. The
assigned metadata included the care component categories; a flag
indicating whether the item was from a standardized assessment
scale, such as the Morse Fall Scale, and the types of information
that the item represented in the context of providing nursing care.
We labeled a data item as ‘‘assessment’’ when it described
patient status at a fine-grained level, which could be synthesized
to draw a nursing diagnosis [11]. The ‘‘diagnosis’’ label was
assigned when a data item described a specific nursing-sensitive
problem based on various nursing assessment data. The nursing
diagnostic statements often included potentiality of the identified
problem and causal factors [11]. For example a data item ‘‘skin
redness: present’’ and ‘‘(skin redness) site: coccyx area’’ were
labeled as ‘‘assessment’’ while a related statement ‘‘potential for
altered skin integrity due to immobility’’ would have been labeled
as ‘‘diagnosis’’ if the forms and templates we analyzed contained
this statement.
After collaboratively reviewing 50 sets of normalized expres-
sions and their original expressions for training purposes, the
reviewers divided the remaining sets and performed an indepen-
dent review. Fig. 3 is the screenshot of the content analysis tool
that we used for this review. To understand the nature of the data
that nurses document, descriptive statistics on the distributions of
various metadata and the level of redundancy in the documenta-
tion items were produced.
3.4. Chart review
After obtaining an approval from the Internal Review Board
(IRB), we randomly retrieved medical records of 20 patients who
had stayed in one of the medical or surgical intensive care units at
the testing hospital during the year of 2007. We focused on the
ICU patients assuming that the higher severity level would result
184 H. Kim et al. / Computers in Biology and Medicine 41 (2011) 182–189
Fig. 3. The review screen of the content analysis tool.
in richer documentation. Patient’s length of stay varied from 2 to
34 days. We reviewed the first 2 days of the stay.
The purposes of this chart review were to investigate (1)
whether the key information on carrying out nursing care is
captured in the current documentation with sufficient depth and
breath to comprehend how the nursing care was determined,
planned, and provided; (2) what kind of information was
documented in the free-text field ‘‘nursing observation’’ of the
ICU flowsheets.
Through the chart review we collected six of the seven data
types that current paper-based documentation intends to capture
(as described in the background section of this paper). We excluded
the ‘‘synthesis of patient status toward indentified nursing goals’’
from the analysis for two reasons. First, this type of information has
already been recognized as poorly documented: nurses often use
the progress note to record assessment data that are not
documented on the flowsheet, or to repeat the assessment data
already documented somewhere else on the flowsheet. Second, the
gist of the synthesis information should be reflected in continuous
assessment thus focusing on evaluating documentation quality of
ongoing assessment data was considered of greater importance.
Therefore, the specific review process included the collection
of the six data types: nursing diagnoses, expected goals, and
planned interventions from the plan of care forms; baseline
assessment data that would have led to the nursing problems
from the admission assessment form; continuous assessment and
intervention data relevant to the identified nursing diagnoses
from the flowsheets and the progress note. During the chart
review we also collected all of the free-text entries made to the
free-text field of the flowsheet labeled as ‘‘nursing observation’’.
The data obtained from the chart reviews was entered into a
Microsoft Access database designed to guide the process and to
facilitate consistency of data collection.
After the completion of chart review we created a database
application to evaluate the documentation completeness of the
nursing care. This application displayed each nursing diagnosis
with other types of data including associated goals, planned
interventions, baseline assessments, continuous assessments, and
continuous interventions. Each type of data was evaluated with
three ordinal categories: ‘‘Acceptable’’—the data was relevant,
provide enough information on the related nursing care, and
expressed in a clearly understandable way; ‘‘Somewhat accepta-
ble’’—the data was relevant and expressed in a clearly under-
standable way, but not enough to provide complete information
on the nursing care; ‘‘Unacceptable’’—either related data was
nonexistent, irrelevant, or expressed in an incomprehensible way.
The 4 nurse reviewers collaboratively evaluated a small number
of cases for training, then divided the remaining cases and
 H. Kim et al. / Computers in Biology and Medicine 41 (2011) 182–189 185

Fig. 4. The review screen of the chart review analysis.

independently evaluated them. Fig. 4 is the screenshot of the tool Table 1

used for this evaluation. frequency of the documentation items.
Free-text entries were reviewed by the first author. After
Category Raw items Normalized items
duplicates were eliminated, the unique entries were categorized (row percent) (row percent)
into the care component categories.
Assessment 762 (58.93%) 583 (55.63%)
Diagnosis 11 (0.85%) 6 (0.57%)
4. Results Intervention 243 (18.79%) 204 (19.47%)
Other 277 (21.42%) 255 (24.33%)
Column total 1293 1048
4.1. What nurses document

A total of 1293 documentation items were collected from the
25 forms. The number of items was reduced to 1048 when
counted only the unique (i.e., normalized) ones, indicating about
23% of them are currently documented in multiple places. More
than half of the items fell in the assessment category. About a
quarter of the items did not fit into any care process categories
thus grouped as ‘‘other’’ (see Table 1).
The most common mode of data entry was free-text (59%) and
Boolean (30%). Only 11% of the items were documented using pre-
defined pick-lists. Twenty four (2.3%) of the 1048 unique items
were from standardized assessment scales.
The distribution of the care component categories are
presented in Fig. 5. The most frequently used category was
‘‘health behavioral’’ and psychological categories (i.e., self-
concept, coping) were among the least. Eighteen items that were
unrelated to nursing care (e.g., room number, time of unit arrival,
etc.) were not assigned to care component categories.
4.2. Documentation of the nursing care
We retrieved 81 nursing diagnoses from the 20 patient
records. The number of diagnoses assigned to patients varied
from 1 to 7. The 81 diagnoses were grouped into 13 areas. We did
not use the care component categories this time because they
were too abstract to represent the problem areas. The majority of
the problems were related to the physiological status. ‘‘Cardio-
vascular’’ and ‘‘Skin Integrity’’ were the two most frequently
appeared problem areas (see Fig. 6).
The evaluation categories assigned to the 6 types of data were
converted to numeric scores: ‘‘acceptable’’ to 2, ‘‘somewhat
acceptable’’ to 1, and ‘‘unacceptable’’ to 0. The continuous
assessment data was the best documented type of data, with an
average score of 1.47, and the planned intervention was rated
least acceptable, with an average score of 0.01. The average score
of the nursing diagnoses was 1.17.
186 H. Kim et al. / Computers in Biology and Medicine 41 (2011) 182–189

0% 5% 10% 15% 20% 25%

Health Behavioral (N=224)
Physical Regulation (N=110)
Medication (N=88)
Cardiac (N=74)
Safety (N=68)
Respiratory (N=68)
Skin Integrity (N=59)
Bowel/Gastric (N=48)
Fluid Volume (N=43)
Cognitive (N=41)
Sensory (N=34)
Urinary Elimination (N=33)
Nutritional (N=26)
Tissue Perfusion (N=25)
Role Relationship (N=24)
Activity (N=22)
Metabolic (N=18)
Life Cycle (N=9)
Coping (N=8)
Self-Care (N=6)
Self-Concept (N=4)

Fig. 5. The distributions of the care component categories.

Average score
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7

cardiovascular (n=16)

skin integrity (n=13)

pain (n=12)

respiratory (n=12)

neurologic (n=6)

infection (n=6)

nutrition (n=6)

safety-fall (n=4)

education (n=2)
Problem
urinary elimination (n=1)
Goal
gastrointestinal (n=1) Planned Intv
Baseline Assess
mobility (n=1)
Cont. Assess
metabolic (n=1) Cont. Intv

Fig. 6. Average documentation quality scores.

The six scores were added up then divided by the possible
maximum total score of 12 to calibrate the overall score to 0 to 1
for easy interpretation. The overall average score of the 81
documentation cases was 0.43. The highest scored case, with
0.83, was the one with the nursing diagnosis ‘‘potential for
change in neurologic signs due to intraventricular hemorrhage,’’
where the reviewers considered that the quality of the
associated goals, the baseline and the continuous assessment
data, and the continuous intervention data were all acceptable.
However, this case did not have any planned intervention data.
Indeed, when compared by problem areas, the ‘‘neurologic’’
area was the best documented, with and overall average score
of 0.58.
The lowest overall average score was 0.08 and it belonged to
the case with the nursing diagnosis of ‘‘potential for alteration in
endocrine function,’’ where no other related data was found. The
‘‘metabolic’’ was the lowest scored problem area as this case was
its sole member. Fig. 6 shows the overall average score of each
problem area. The average score of each type of data were divided
by 12 for easy comparison.
 H. Kim et al. / Computers in Biology and Medicine 41 (2011) 182–189
Table 2
Frequency distributions of the free text entries by the care component categories
and by the relevancy to the field.
Care component Relevant Irrelevant
Health behavioral 11 1 and evaluating ‘‘nursing sensitive’’ outcomes will be challenging
Activity 6 1
Physical regulation 5 0
Cognitive 3 5 (5)
Skin integrity 2 2 (1)
Bowel/gastric 1 1
Coping 1 0
Sensory 1 3
Fluid volume 0 2 (2)
Medication 0 2
Respiratory 0 2 (1)
Self-care 0 2
Column total 30 21
In parentheses are the numbers of entries that are nursing observation related but
have other designated fields to document.
4.3. Use of the ‘‘nursing observation’’ field
A total of 51 unique entries collected from this field were
classified into the 12 care component categories (see Table 2).
Most of the entries falling in the ‘‘health behavioral’’ category
were describing disposition of a patient (e.g., ‘‘to angio,’’ ‘‘back to
the floor’’). Most of the entries of the ‘‘activity’’ category were
describing a patient’s activity status (e.g., ‘‘out of bed to chair,’’
‘‘sitting in chair for 40 min’’). About 60% of the free text entries
were deemed relevant to the field as they described a kind of
nursing observation, which has no other field to document in the
flowsheet. Nine entries were deemed irrelevant to the field, even
if they described a nursing observation, because they had a
designated field to document in the flowsheet (in parentheses,
Table 2). The remaining 11 entries were deemed irrelevant as they
described interventions (e.g., administering PRN medication).
Although there was no designated field for these entries in the
flowsheet, the flowsheet provides a field labeled ‘‘additional data,’’
which should contain this type of intervention data.
5. Discussion
We observed many problems that paper-based documentation
systems commonly have, such as non-standardized documenta-
tion field labels, frequent use of free-text descriptions and
inconsistent use of free-text fields. Studies showed that these
problems can persist in a poorly designed EHR [2–4]. Despite the
fact that our study had a very narrow scope and employed
subjective measurement methods that limit the generalizability
of findings, we have gained some useful insights on how to
configure a computerized bedside documentation system at PHS.
We observed that many documentation items are presented
with different lexical forms. Recognizing them as synonymous
items is critical to avoid redundant documentation and accurate
processing of the documented data in the computerized system.
In order to do so, the irregular item names will need to be
standardized in the computerized system, or encoded with
standardized terminology systems. Frequent use of free text
entries also means that developing standardized coded value sets
(e.g., pick-lists) for many free-text items needs to be included as a
high priority task in designing the new documentation system to
support reuse of the documented data.
From the forms and templates analysis, we found that nursing
documentation focused mostly on capturing assessment data.
Paucity of diagnosis items was expected as they are usually
187
documented as free-text thus entry field labels of the forms and
templates are unlikely to reflect specific diagnosis concepts.
However, we found the low fraction of intervention items
potentially problematic. Improving nursing sensitive outcomes
is gaining increasing attention [12]. However, accurately defining
without adequate documentation of nursing interventions.
Although the coverage was somewhat unbalanced, the dis-
tribution of the care component categories shows that the current
documentation covers the various nursing care domains repre-
sented by the categories. However, current documentation seems
less focused on psychological aspects of nursing care. The new
documentation system needs to consider enhancing the psycho-
logical documentation.
Since the ‘‘health behavioral’’ category is defined broadly as
nursing activities related to maintain and regain the health status
of the patient [10] various content items could be related to it,
from care coordination to patient education. Indeed, the majority
of the items categorized as ‘‘Other’’ in Table 1 were health
behavioral items. A few examples of these items are arranging
diagnostic test, handling patient belongings, obtaining contact
information of the long term care facility, among others. This
shows that nurses’ responsibility for documentation is stretched
to non-clinical (‘‘housekeeping’’) data. In addition, this implies
that the ‘‘assessment,’’ ‘‘diagnosis,’’ and ‘‘intervention’’ categories,
which reflect the problem solving oriented aspect of nursing care
conducted through the nursing process, are not sufficient to
capture the health coordination and management aspect of
nursing care provided outside the nursing process.
The number of data items was reduced by 23% when only
unique items were counted. To identify whether these repeated
items reflect true redundancy in documentation, we looked at
whether any data items appear multiple times in a single form.
About half of the repeated items were spread in ten forms.
The number of repetition of one item in a single form varied from
2 to 4. Most of the repetitions were not true redundancy because
they were to capture the data at different time points (e.g., vital signs
measured at pre-procedure and at post-procedure). However, we
observed a few true redundancies: ‘‘whether the patient is pregnant’’
was asked twice to assess nutritional requirement and sexual/
reproductive status, ‘‘history of major surgery’’ to assess nutritional
requirement and venous thrombo-embolism risk assessment. These
items could be unified into a single item in the computerized system
and let the system carry forward the data to the places that require
the same information.
Analysis on the data items appearing in multiple forms to
determine documentation redundancy was not done in this study
as it requires considering documentation workflow and temporal
information. However, this analysis will need to be done in the
future study to obtain more accurate insights on documentation
redundancy.
It is not surprising that the majority of the 81 nursing
problems that we had collected by chart review were related to
physiological status because the scope was limited to medical or
surgical ICUs. However, unlike our positive expectation on
documentation quality in ICU settings, the 20 patient charts
investigated in this study were deemed failing to deliver sufficient
and accurate data on problem solving oriented nursing care.
Two major problems leading to the failure were identified. The
most frequently observed problems were incomplete documenta-
tion. The data required to understand the complete picture of
the nursing care (i.e., the six types of data) was often not found
in the records that we had reviewed. This seems to be a common
problem identified by other nursing documentation studies
[7,13,14]. We believe the most significant contributing factor
to this problem is a poor documentation design that fails to
188 H. Kim et al. / Computers in Biology and Medicine 41 (2011) 182–189
support: (a) the capture of data required for carrying out nursing
care and (b) nursing workflow. For example, the plan of care form
contains a list of pre-defined intervention categories, which may
or may not be relevant to the identified nursing problem.
However, it does not provide enough space to document
additional interventions. This design issue might lead to the poor
documentation quality of the planned interventions.
Nurses are likely to take a process similar to our chart review
process to review the patient data to understand the status of
the care they are providing. Although the chart review was
limited to the 4 major forms, we found that browsing the paper
records to find relevant data scattered in disparate places was an
extremely inefficient process. To address these issues, the
documentation system design team at PHS is conducting
extensive analyses on workflows in relation to documentation
content. The team is also building terminological foundations
of the documentation content to ensure that the new documenta-
tion system will enable efficient retrieval and presentation of the
relevant data while minimizing manual browsing and searching
for the data [15].
Improper writing style was another frequently encountered
issue. This issue was found mostly in diagnostic statements. A
diagnosis and a goal should be stated with enough specificity to
guide the relevant interventions and outcome evaluations.
However, the diagnostic statements that we had reviewed often
failed to include relevant details, e.g., potentiality and associated
factors, which are required to determine relevant interventions.
For example, ‘‘potential for altered skin integrity related to
pressure ulcer’’ and ‘‘altered skin integrity related to surgical
treatment’’ are two distinct diagnoses that require different sets
of interventions. However, they were often poorly stated as
‘‘altered skin integrity’’ or ‘‘skin integrity’’.
Retrospectively evaluating documentation completeness is a
challenging task when an established reference standard does not
exist. In this study such a standard would have been the actual
patient status and the care provided. The goal of the chart review
analysis was to investigate whether the current paper-based
documentation provided enough information on the nursing care
provided to the patient as perceived by those who did not
participate in the patient care, such as the reviewers in this study.
In this sense, the results of the chart review still hold value
although it was done without knowledge of the complete patient
story.
Studies show that the documentation quality was improved by
establishing a clear documentation model that reflects the
nursing practice of an institution and by providing training on
performing documentation following the proposed model [7,9]. In
addition to training, a computerized documentation system with
an explicit documentation model can improve the bedside
documentation quality, and also enable detailed auditing to
identify areas that are frequently incomplete or inadequately
documented.
In spite of the narrow scope, we have gained some useful
insights on how to configure a computerized bedside documenta-
tion system at PHS. However we will need to expand this analysis
by including more documentation forms and templates and by
reviewing more patient charts to ensure the findings of this study
can be generalized across various health care domains. In
addition, the scoring scheme used in this study needs to be
scrutinized further to minimize subjectivity and to maximize the
quality of the information that evaluation scores deliver.
We excluded the data type of ‘‘synthesizing patient status
progressing toward identified nursing goal’’ from the chart review
analysis because we were already aware of that this type of data
was poorly documented. We were able to confirm this problem in
this chart review: we did not observe any ‘‘synthesis’’ information
documented in the progress note. Instead, the progress notes
were used to document assessment data that could have been
recorded in the flowsheet. This persisting problem will also need
to be further investigated in a follow up study.
6. Conclusion
The first step toward developing a computerized documenta-
tion system that supports complete and accurate documentation,
as well as reuse of the documented data, is to understand the
problems of an existing paper-based documentation system.
Through this limited scope analysis on the nursing documentation
content, we gained a number of useful insights on designing a
computerized documentation system at PHS. Some of the most
relevant insights include the extent of redundancy in the
documentation content, areas where more structure needs to be
introduced to capture the data on nursing practice more
completely and accurately, and multiple design considerations
for supporting the capture and display of critical data to support
patient-centered nursing care.
7. Summary
A small scale documentation analysis was conducted to explore
the medical and surgical nursing content of the patient record at a
large teaching hospital affiliated with Partners Healthcare System
(PHS), in preparation for a computerized documentation system. The
analysis consisted of 2 parts: (1) analyzing 25 existing structured
forms to investigate the nature of nursing documentation; (2)
reviewing 20 sets of nursing care plans, admission assessment
forms, flowsheets, and nursing progress notes randomly selected
from ICUs, to investigate the completeness of nursing documenta-
tion in the context of nursing process.
A total of 1293 documentation items were collected from the 25
forms. This number was reduced to 1048 when only the unique ones
were counted, indicating that about 23% of identical items were
given different labels. More than half of the items fell in the
assessment category. About a quarter of the items did not fit into any
care process categories thus grouped as ‘‘other’’. The most common
mode of data entry was free-text (59%) and Boolean (30%). Only 11%
of the items were documented using pre-defined pick-lists.
The 1048 unique documentation items were mapped to the
care component categories of the Clinical Care Classification (CCC)
system. The coverage was somewhat unbalanced. For example,
current documentation seemed less focused on psychological
aspects of nursing care. However, in general, the distribution of
the care component categories showed that the current docu-
mentation covered complete aspects of nursing care represented
by these categories.
The chart review analysis showed that the current documentation
failed to deliver sufficient and accurate data to represent nursing
care. Two major problems leading to the failure were identified:
incomplete documentation of nursing care process (e.g., missing
assessment data, missing goal statement, etc) and improper writing
style that caused confusion in interpreting the documented data.
The first step towards developing a useful documentation system
is to understand the problems of an existing paper-based documen-
tation system. Through this limited scope analysis on the nursing
documentation content, we gained a number of useful insights on
designing a documentation system at PHS. Some of the most relevant
insights include the extent of redundancy in the documentation
content, areas where more structure needs to be introduced to
capture the data on nursing practice more completely and accurately,
and multiple design considerations for supporting the capture and
display of critical data for providing nursing care.
 H. Kim et al. / Computers in Biology and Medicine 41 (2011) 182–189
Conflict of interest statement
None declared.
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