Val. XXVI, No. 4 Printed in U . S . A .
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Copyright 0 1978 by the American Geriatrics Society
Nurses’ Notes on Nursing Home Patients: Are Thev Effective? J
JOHN B. HOWARD, MD* and KENNETH E. STRONG, FACNHAt
Roland Thatcher Nursing Home, Wareham, Massachusetts ABSTRACT: The notes written by nurses in a level-I11 nursing home were reviewed in detail. They were found to be neither pertinent nor meaningful in most cases. The daily writing of these notes required a large percentage of the nurses’ time but they were seldom, if ever, read by physicians. An alternate system of writing notes on a weekly basis is suggested. on incidents, it was found that the nurses usually made notes concerning the incident, regardless of the shift during which it occurred. The specific content of the nurses notes was reviewed in detail. It became clear that the notes consisted mainly of the documentation of the duties performed by the nursing staff and the documentation of how well the patient tolerated his designated diet. Examples of the typical nurses’ notes were: “Routine AM care, up and about ad lib, 1500 cal. diabetic soft diet taken. In TV room a t times.” “Tub bath, up and about, 1800 cal. diet taken well. In TV room or lying in bed when not at activities class.” “Assist. AM care, ambulating, 1600 cal. diabetic diet taken well. Good day. No change.” “Complete AM care. Bed bath given. General skin care. 1500 cal. diet taken well. Given bed pan as needed.” “OOB. Complete AM care given and dressed with assistance. 8 gm. salt diet taken well. Sat in gerichair in room. Good day.” “Complete AM care and skin care. Patient remained in bed all of shift. 1500 cal. diabetic diet taken well.” These notes were all written on different patients with multiple and varied medical problems. For any one patient the day-to-day notes were repetitive and rarely showed any significant variation. Of the 656 notes reviewed, only ? described any change or included any new information. Three of these were on a patient with severe venous ulcerations on both legs. The time required to write nurses’ notes was also determined during this study. On the aver-
Who writes the nurses’ notes in a nursing home? For what purpose are they written? Do they contribute to the care of the nursing home patient? In order to answer these questions, the authors studied the nurses’ notes a t a 100-bed, level-111, proprietary nursing home. The study was carried out over a four-week period. The review covered the nurses’ notes written for each patient for a period of four consecutive days. Particular attention was paid to notes indicating a change in the patient’s medical condition, and to the relevancy of each note to the continuing medical problems that the patient might have. We first determined which levels of nursing personnel were writing the nurses’ notes. A total of 656 notes was studied: 510 notes (77 percent) were written by nursing aides, 103 (16 percent) by licensed practical nurses (LPNs), and the remaining 43 by registered nurses (RNs). All notes written by aides were co-signed by an RN or an LPN. At the nursing home studied, State regulations require that nurses’ notes be written only during the day shift of each 24-hour period. Notes are not required on the other two shifts. Seven of the notes that we studied had been written during the evening shift. On questioning, the nursing staff felt that since nurses’ notes were written during the day on a routine basis, they need not write any notes unless there was a particular incident or a dramatic change in the patient’s status. In a retrospective review of the reports
____
* Medical Director, Roland Thatcher Nursing Home. Address for correspondence: John B. Howard, MD, 106 Main Street, Wareham, MA 02571. t President, Extended Care Consultants, Wareham, MA.
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HOWARD AND STRONG
age each of the 9 aides spent one hour per eighthour shift writing notes. This represented 14 percent of her working time. In addition, one RN or LPN spent one hour of her time co-signing the notes. The cost of the time spent by nursing personnel in writing notes is considerable. The cost of an aide a t this facility, including wages and additional benefits, is estimated to be $5 per hour. The cost of writing nurses’ notes, then, is about $50 per day or $18,250 per year. Ten physicians routinely care for patients at this facility (4 internists, 3 general surgeons and 3 general practitioners). All of these physicians stated that they did not read nurses’ notes because they felt the notes did not contain any significant information. It is of interest that one of these physicians, the medical director at this facility, and one of the authors of this paper (JH), had never read any of the nurses’ notes until this study was started. The physicians were asked how they obtained information about the patients for whom they were caring. The principal source of information was found to be the charge nurse. The physicians were in the habit of reviewing both the vitalsign sheets and the medication order sheets. When they made rounds at the nursing home the charge nurses were asked to make rounds with the physician and bring him up to date on each patient’s status. When information was requested by telephone, here also the charge nurse was the major source of information. It is well known that physicians try to get through nursing home rounds as quickly and efficiently as possible. At this facility the administrator had instituted a policy whereby questions regarding patients would be listed on a piece of paper attached to the order book for each physician. In addition, any new information that the nurses felt the physician should be aware of would be written on this paper. This policy has been well received by the medical staff. Given the fact that nurses’ notes usually are not read by physicians and that they are written mainly by aides with whom physicians do not often consult when making rounds, it seems clear that the notes do not contribute to the care of the patient. The authors have addressed themselves to the task of suggesting an alternate system for nurses’ notes, aimed particularly at
VOl. X X V I
achieving effective communication between the nursing staff and the physician. Any change in the writing of nurses’ notes should be aimed at a reduction of “paper work.” In this level-I11 facility, it would seem that a concise and well-thought-out note, written once a week by the charge nurse, would adequately describe the patient’s progress. These notes should clearly reflect any change in the patient’s status and should comment on any active medical problems. A note on a patient with coronary artery disease, for example, should reflect nitroglycerine usage and the activity level. If active medical problems are evolving, the nurses should be encouraged to write notes as often as they feel they are necessary. This might well mean notes on a given patient during each shift. If the notes are to be read by physicians, the most visible place to write such notes would be on the physician progress note sheets. In this event, the designation of the sheets should be simply “progress notes.” There is precedence for combined progress notes a t the hospital level where so-called “physician progress notes” often include notes written by the social worker, the physical therapist and the physician assistant. In effect, by giving the charge nurse the responsibility of evaluating patients on a regular and continuing basis, one is designating the nurse as a physician assistant. It is to be emphasized that the physician should not be excused from writing regular notes. Rather, he should be expected to be more thorough in caring for his patients by virtue of his better access to more significant information. No doubt there remains the need to document in some way the daily care given by the aides. Perhaps this could be done by initialing a checklist on a work sheet a t the same time that vital signs are being charted. There seems to be a fashion among regulatory agencies to document all sorts of data, regardless of whether or not these data contribute to the care of the patient. The plan that we have suggested would save nurses’ time and result in the writing of notes that are more visible and useful to the physician. The emphasis is on achieving better care for the patients, rather than on mere slavish routine documentation as stressed by many regulatory agencies.
189
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Copyright 0 1978 by the American Geriatrics Society
Nurses’ Notes on Nursing Home Patients: Are Thev Effective? J
JOHN B. HOWARD, MD* and KENNETH E. STRONG, FACNHAt
Roland Thatcher Nursing Home, Wareham, Massachusetts ABSTRACT: The notes written by nurses in a level-I11 nursing home were reviewed in detail. They were found to be neither pertinent nor meaningful in most cases. The daily writing of these notes required a large percentage of the nurses’ time but they were seldom, if ever, read by physicians. An alternate system of writing notes on a weekly basis is suggested. on incidents, it was found that the nurses usually made notes concerning the incident, regardless of the shift during which it occurred. The specific content of the nurses notes was reviewed in detail. It became clear that the notes consisted mainly of the documentation of the duties performed by the nursing staff and the documentation of how well the patient tolerated his designated diet. Examples of the typical nurses’ notes were: “Routine AM care, up and about ad lib, 1500 cal. diabetic soft diet taken. In TV room a t times.” “Tub bath, up and about, 1800 cal. diet taken well. In TV room or lying in bed when not at activities class.” “Assist. AM care, ambulating, 1600 cal. diabetic diet taken well. Good day. No change.” “Complete AM care. Bed bath given. General skin care. 1500 cal. diet taken well. Given bed pan as needed.” “OOB. Complete AM care given and dressed with assistance. 8 gm. salt diet taken well. Sat in gerichair in room. Good day.” “Complete AM care and skin care. Patient remained in bed all of shift. 1500 cal. diabetic diet taken well.” These notes were all written on different patients with multiple and varied medical problems. For any one patient the day-to-day notes were repetitive and rarely showed any significant variation. Of the 656 notes reviewed, only ? described any change or included any new information. Three of these were on a patient with severe venous ulcerations on both legs. The time required to write nurses’ notes was also determined during this study. On the aver-
Who writes the nurses’ notes in a nursing home? For what purpose are they written? Do they contribute to the care of the nursing home patient? In order to answer these questions, the authors studied the nurses’ notes a t a 100-bed, level-111, proprietary nursing home. The study was carried out over a four-week period. The review covered the nurses’ notes written for each patient for a period of four consecutive days. Particular attention was paid to notes indicating a change in the patient’s medical condition, and to the relevancy of each note to the continuing medical problems that the patient might have. We first determined which levels of nursing personnel were writing the nurses’ notes. A total of 656 notes was studied: 510 notes (77 percent) were written by nursing aides, 103 (16 percent) by licensed practical nurses (LPNs), and the remaining 43 by registered nurses (RNs). All notes written by aides were co-signed by an RN or an LPN. At the nursing home studied, State regulations require that nurses’ notes be written only during the day shift of each 24-hour period. Notes are not required on the other two shifts. Seven of the notes that we studied had been written during the evening shift. On questioning, the nursing staff felt that since nurses’ notes were written during the day on a routine basis, they need not write any notes unless there was a particular incident or a dramatic change in the patient’s status. In a retrospective review of the reports
____
* Medical Director, Roland Thatcher Nursing Home. Address for correspondence: John B. Howard, MD, 106 Main Street, Wareham, MA 02571. t President, Extended Care Consultants, Wareham, MA.
188
HOWARD AND STRONG
age each of the 9 aides spent one hour per eighthour shift writing notes. This represented 14 percent of her working time. In addition, one RN or LPN spent one hour of her time co-signing the notes. The cost of the time spent by nursing personnel in writing notes is considerable. The cost of an aide a t this facility, including wages and additional benefits, is estimated to be $5 per hour. The cost of writing nurses’ notes, then, is about $50 per day or $18,250 per year. Ten physicians routinely care for patients at this facility (4 internists, 3 general surgeons and 3 general practitioners). All of these physicians stated that they did not read nurses’ notes because they felt the notes did not contain any significant information. It is of interest that one of these physicians, the medical director at this facility, and one of the authors of this paper (JH), had never read any of the nurses’ notes until this study was started. The physicians were asked how they obtained information about the patients for whom they were caring. The principal source of information was found to be the charge nurse. The physicians were in the habit of reviewing both the vitalsign sheets and the medication order sheets. When they made rounds at the nursing home the charge nurses were asked to make rounds with the physician and bring him up to date on each patient’s status. When information was requested by telephone, here also the charge nurse was the major source of information. It is well known that physicians try to get through nursing home rounds as quickly and efficiently as possible. At this facility the administrator had instituted a policy whereby questions regarding patients would be listed on a piece of paper attached to the order book for each physician. In addition, any new information that the nurses felt the physician should be aware of would be written on this paper. This policy has been well received by the medical staff. Given the fact that nurses’ notes usually are not read by physicians and that they are written mainly by aides with whom physicians do not often consult when making rounds, it seems clear that the notes do not contribute to the care of the patient. The authors have addressed themselves to the task of suggesting an alternate system for nurses’ notes, aimed particularly at
VOl. X X V I
achieving effective communication between the nursing staff and the physician. Any change in the writing of nurses’ notes should be aimed at a reduction of “paper work.” In this level-I11 facility, it would seem that a concise and well-thought-out note, written once a week by the charge nurse, would adequately describe the patient’s progress. These notes should clearly reflect any change in the patient’s status and should comment on any active medical problems. A note on a patient with coronary artery disease, for example, should reflect nitroglycerine usage and the activity level. If active medical problems are evolving, the nurses should be encouraged to write notes as often as they feel they are necessary. This might well mean notes on a given patient during each shift. If the notes are to be read by physicians, the most visible place to write such notes would be on the physician progress note sheets. In this event, the designation of the sheets should be simply “progress notes.” There is precedence for combined progress notes a t the hospital level where so-called “physician progress notes” often include notes written by the social worker, the physical therapist and the physician assistant. In effect, by giving the charge nurse the responsibility of evaluating patients on a regular and continuing basis, one is designating the nurse as a physician assistant. It is to be emphasized that the physician should not be excused from writing regular notes. Rather, he should be expected to be more thorough in caring for his patients by virtue of his better access to more significant information. No doubt there remains the need to document in some way the daily care given by the aides. Perhaps this could be done by initialing a checklist on a work sheet a t the same time that vital signs are being charted. There seems to be a fashion among regulatory agencies to document all sorts of data, regardless of whether or not these data contribute to the care of the patient. The plan that we have suggested would save nurses’ time and result in the writing of notes that are more visible and useful to the physician. The emphasis is on achieving better care for the patients, rather than on mere slavish routine documentation as stressed by many regulatory agencies.
189
