Julianna Paradisi, RN, OCN, writes a monthly post for this blog and works as an infusion nurse in outpatient oncology. Editor’s note: this post has been slightly revised for clarity since its initial publication a day ago.
Heroines of Nursing, mixed media collage by julianna paradisi, 2013. Text by Florence Nightingale
Previously I’ve written that I have a new employer. Part of this transition is relearning how to use the electronic health record (EHR). Fortunately, this new employer uses the same program as my last. However, that version was EHR-lite compared to the one we use now.
For instance, the new system contains an abundance of “smart phrases” that are used to lessen time spent writing nursing notes. If you are unfamiliar with smart phrases, an uncomplicated explanation is that they are preconstructed phrases chosen from those commonly found in charting, such as “The patient arrived ambulatory for IV infusion.” Instead of typing in this phrase, nurses can click on it from a computer screen menu, and voilà! The entire phrase is electronically inserted into the notes.
Smart phrases, like charting by exception (in which a nurse clicks on boxes to document a patient’s assessment, IV status, and more) are intended to allow nurses to spend more time at the bedside providing patient care, rather than writing about it. In theory, this is a good idea. However, something about using smart phrases makes me balk. Reflecting on this feeling, I realized that:
a) I write more descriptively than the authors of smart phrases, and
b) I want to chart in my own words.
On further reflection, I finally realized why so many nurses react negatively to exception-based charting: Checking boxes doesn’t allow nurses to describe what we actually do in our own words. I hadn’t understood this until now. Evidently, for me the line of tolerance is drawn at smart phrases.
Not all nurses are compelled to write as I am, but most take a great deal of pride in their work. For some, charting in the nursing notes is the only recorded evidence of their special talent for making a nursing diagnosis, implementing interventions, and reporting the outcome in the natural arc of a story.
For instance, a nurse could have a patient who is also a violinist whose chemotherapy has left her with profound peripheral neuropathy in her fingertips. She is no longer able to play the violin, which she’s long considered her life’s purpose. She relates this information to her nurse. Both patient and nurse are aware that despite this loss, the patient will not survive. They discuss the situation, maybe reaching a philosophical or spiritual peak for the patient, or maybe finding that the patient no longer wishes to continue treatment. Or maybe the patient inquires about Death with Dignity, because for her, life without the violin is not worth living.
A nurse would not chart this as I have written it above, but would include enough information to back up a need for further assessment and consultations perhaps with palliative care, spiritual care, or social services. Perhaps an antidepressant medication would help.
A template reduces the note to a report of peripheral neuropathy, and does not capture the patient’s true story, nor for that matter, the role the nurse plays in it.
In this way, traditional nursing notes afford all nurses the opportunity to become writers. Hence, for some nurses, the convenience of smart phrases and exception charting represent a loss of voice, rather than a means of convenience.
Well, you might say, maybe with charting by templates there’s valuable information lost, information that could improve patient care, but at least nothing prevents literary-minded nurses from writing their stories elsewhere if they really want to. To some degree, this is so—but over time, I’ve come to realize that nurses are in fact very much restricted in telling stories even outside of the nursing notes. Those of us who write for publication spend a great deal of time changing details and patient identifiers even as we strive to keep the core of our message intact and maintain a nonfiction status. In fact, some of the very best stories cannot be told, because it’s their unique blend of identifiers combined with events that make a particular story richly nuanced and compelling. These stories are lost, out of commitment to patient privacy, or the fear of losing our jobs.
Longhand charting subverts one more obstacle of nurse writing: The media’s expectation that nurses must frame our stories in the context of a relationship for them to be considered engaging enough for publication. Popular stories written by nurses orbit relationships in the form of conflict between nurse and physician, nurse and hospital administration, or sad and often bittersweet interactions with patients. In this manner, nurses who are writers inadvertently recreate commonly accepted stereotypes over and over, adding little that’s new to the public’s perception of nursing.
Unlike other examples of character-driven literature, stories by nurses expressing feelings about our work without the context of a single relationship are rarely considered for publication. A common media phrase for this phenomenon is “if it bleeds, it leads.”
As it stands, writing about the quiet interventions of cooling a fever or listening to a dying patient’s intimate confession is considered either un-newsworthy or a violation of privacy, appropriate only if written in the nursing note. No electronic check boxes or smart phrases exist to otherwise capture these moments so deeply inherent in the lives of nurses.
Nurses need avenues for writing about what we do, and experience without the limitations presented by a patient’s story or an argument with a physician. Until recently, nursing notes provided this avenue, but this is coming to a close.
If nurse writing is reduced to clicking smart phrases, checking boxes, or explaining nursing only through relationships, much of the richness of our stories will be lost. Writing fiction is perhaps an alternative for some, but I long for the day when nurses can write down their truth, without smart phrases or fear.
Lisa Day wrote a good piece on this a while back: What is documentation for? Am J Crit Care. January, 2009 1 (1); 77-80.
My experience with “smart phrases” was that they were not very smart at all. They were not intuitively named and there was no list for reference; we just supposed to remember them. And of course there is the “violinist problem,” as the author explained. The story goes missing for the benefit of regulatory compliance. JCAHO and CMS don’t care about the story, so we don’t tell it anymore. This is a dehumanizing loss; patients are reduced to a list of checkboxes. Even the regulators complain that they can’t discern “the story” from the healthcare record anymore. Maybe I’m just old, but we used to claim that our documentation communicated what nurses do and how we think. We used to say it was important to document our contributions to health care. The EHR makes nursing look like a set of tasks, and that worries me.
I am not sure why it has to be all or nothing. There should be the capability of adding your own narrative to any note. The templates and smart phrases will work most of the time, and that saves time. Nurses can then devote extra time to the minority of patient encounters that would benefit from a more detailed account or story.
It would be so much better if standardized nursing language was embedded in the EHR. It would not tell the whole story, but it would at least indicate nursing diagnosis, interventions and outcomes. I think we, as nurses, need to become more acquainted with the possibilities of standardized nursing language so we can advocate for its usage in our facilities.
Based on tasks and medical diagnosis, I find the template or box does not say enough, without making room for nursing diagnosis, the tailoring of a medical care plan to the unique needs of a particular patient. For many of us, this is the heart of nursing, and perhaps lost in the EHR, as suggested in the study link above.
Answer ‘do EHRs rob nurses of voice?’ is yes: http://bmjopen.bmj.com/content/2/6/e001754.short
I would like to think charting is not the same as writing a story about what we do as nurses. Yes, “smart phrases” help nurses get through a busy day and hopefully communicate what other team members need to know about that patient.
However, nurses can tell their stories in an entertaining and creative manner and submit these stories to the many sites that publish health care stories from both doctors and nurses. Rather than set up road blocks, we nurses need to encourage each other to get our stories told and published.
and of course there is always the problem that you click on the wrong box or the wrong phase and say something entirely different than what you meant