171K+ clicks saved: Inside Johns Hopkins' nurse documentation revamp

Across healthcare, efforts to advance documentation are often focused on enhancing physicians' workflow. But at Baltimore-based Johns Hopkins Hospital, leaders are equally focused on improving documentation in nursing. 

In March, JHH announced its fifth consecutive Magnet Designation, placing it among the 1% of U.S. hospitals that have achieved the designation — the highest national credential a hospital can receive for nursing excellence — at least five times. As part of the designation, the American Nurses Credentialing Center recognized Johns Hopkins with 10 exemplars, one of which recognized the hospital as a leader in nursing informatics. 

Case in point: The hospital has saved nurses 170,620 clicks in four months, April Saathoff, DNP, RN, vice president and chief nursing information officer at Johns Hopkins Medicine, told Becker's.

Conversations about nursing documentation revamp began in March 2023, when leaders received feedback from a survey where nurses were asked to share, "anything that drove them crazy," about documentation, she said. The hospital began putting that feedback into action this year. 

Phase one of a project to revamp nursing documentation involved changes to reassessments. JHH implemented macros to save nurses time when completing reassessments, which essentially gives nurses the ability to click a button that will automatically fill in portions of the reassessment form. 

"Instead of the nurse having to go in and document on every single row on a head-to-toe reassessment for the patient, we now have some fields added to the top where the nurse can document reassessment changes noted or reassessed no changes," Dr. Saathoff said, adding that the changes are saving nurses an average of 13 minutes per reassessment. 

The hospital also added a new nursing handoff tool to make it easier for nurses to see the most relevant and appropriate information they need to know, based on the units they work in. 

The next phase of the project is focused on care planning, with changes slated to take effect in the spring of 2025. 

"We're trying to make it more efficient, more automated and more tied into the nursing workflow because it is cumbersome and takes a lot of steps right now," Dr. Saathoff said. 

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