Healthcare professionals are spending an average of 13.5 hours per week adding to or creating clinical documentation, a 25% increase in the last 7 years, according to a new research report from Nuance and independent research consultancy, Ignetica Ltd.
The report is based on an extensive survey of 966 NHS healthcare professionals from four acute trusts and one mental health and community trust. It gleans insights around the burden Doctors, Nurses and Allied Health Professionals, face in their day-to-day roles when it comes to producing accurate and timely clinical documentation.
It follows a 2015 report and reveals that, although so much has happened in healthcare over the last seven years – from the introduction of new digital tools to a global pandemic – many of the documentation challenges clinicians face have remained the same or worsened. In fact, the report found that the value of time for a consultant doctor searching for missing information and generating clinical documentation is circa £57,000 per doctor, per annum.
The documentation workload has increased
The study discovered that the average time spent creating or adding to clinical documentation per week (13.5 hours) is more than a third of the average clinician’s working hours (37.7). It is also 2.7 hours more than in 2015. Consultant nurses (16.5 hours) and consultant doctors (15.1 hours) are spending the longest on it.
As demands for healthcare services have scaled in recent years due to the pandemic, it’s perhaps unsurprising to see such a high increase in time spent on clinical documentation. Higher patient numbers and a backlog of appointments likely means higher documentation workloads.
However, it is still concerning to see that so much of this documentation is completed by clinicians outside of their working hours. Healthcare professionals report spending an average of 3.16 hours per week adding to clinical documentation in their personal time – with consultant doctors reporting an average of 4.72 hours.
Putting down the pen and paper
Less than half (40%) of respondents cited pen and paper as a main documentation format. This is a positive development since the 2015 study, when 80-90% of clinicians relied on this modality.
This switch has brought a reduction in narrative content (from 69% of time to 42%) in clinical documentation for both inpatients and outpatients. As more clinicians shift to using the EPR to complete their documentation, notes are becoming more structured within teams.
Inaccuracies still causing challenges
Despite the switch from pen and paper to digital platforms like the EPR, there has not been a significant increase in documentation accuracy. In fact, in a quarter (25%) of instances, clinicians report the information they need isn’t available in the records at the right time.
The number one cause for this is unclear and incomplete information in the clinical notes/records (36%). Clinicians also report a significant increase in time waiting for diagnostics and investigation results (23%) and, in some instances, uncertainty in what diagnostics have been requested (19%).
These challenges add to the time clinicians need to spend wrestling with documentation throughout the day. In fact, despite an increase in digitisation, clinicians are still spending 1 hour a day looking for missing information.
“Despite the many technological advancements that have taken place in healthcare over the last seven years, the burden of clinical documentation remains. As workloads continue to grow and healthcare organisations are forced to operate with more limited resources, we are at risk of placing one of our most precious institutions under even more avoidable pressure. If nothing changes, we are likely to see many healthcare staff suffering from burnout, which can have serious repercussions for the entire population.” said Dr Simon Wallace, chief clinical information officer, Nuance.
“Every hour a clinician spends on creating or locating clinical documentation is one less hour spent on patient care. To enable them to get back to doing what they trained for, we must find new ways to help ease the growing burden of administrative responsibilities.” he added.