Improvement Report: Reduction in Nursing Documentation and Retrieval of Patient Information

Gundersen Lutheran
La Crosse, Wisconsin, USA


Mary Stibbe, RN, Nursing Project Leader
Kathy Callan, RHIT, Manager of Clinical Data Services
Carla Steffen, RN, Information Services Systems Analyst
Verona Lachman, RN, 3 West Medical Surgical
Donna Kelly, RN, 3 West Medical Surgical
Jodi Nelson, RN, 6 West Cardiology
Lisa Novak, RN, 6 West Cardiology
Chris Heiderscheit, RN, Quality Improvement Specialist
Michelle La Fleur, RN, Quality Improvement Specialist
Debra Rislow, Director of Information Services
Jean Krause, Director of Quality and Performance Improvement

To reduce the amount of time nurses spend documenting and retrieving information by 50 percent.


  • Reduce the total time to complete a FHP (functional health pattern) and Patient Database during the admission process
  • Reduce the steps in the admission process
  • Eliminate duplication of data between the FHP and the Patient Database

  • Placed Computers in all patient rooms, hallways, and nurses stations
    • Reduced the time to login to the computer
    • Reduce dthe retrieval time of lab results from the computer
  • Streamlined the Admission Process
    • Automated the Functional Health Pattern and Patient Database
    • Reduced data redundancies gathered during the admission process






Summary of Results / Lessons Learned / Next Steps

  • The total amount of time saved in the admission processes is estimated at 1 hour, 1 minute and 31 seconds based on observations and time studies
  • Quality of documentation can now be measured and tracked over time with data being forced field entry
  • Documentation standards for the Admission Intake and FHA are now in place and can be monitored
  • There is now a standard notification process for Social Services, Pastoral Care, Nutrition Services, and Enterostomal Therapy
  • Nursing staff is happy to be using the applications
  • There is an audit process in place to help sustain the change
  • Still need to improve nursing documentation to reduce one more hour of retrieval or documentation time

Lessons Learned
  • Process changes need to drive the technology changes
  • Structured interaction between the design team and Information Systems programmers
  • Piloting the changes with a subset of the larger population in a controlled setting was a very positive strategy
  • Set realistic timelines

Contact Information
Jean Krause
Director of Quality and Performance Improvement
[*Storyboard presentation at IHI's National Forum, December 2003] 
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