Project Giving U Back T.I.M.E.
(Together Implementing Meaningful and Essential Documentation)


Project T.I.M.E.

Reducing Nursing Documentation Burden Project Aims to Give U Back T.I.M.E.

Electronic health records (EHRs) are linked to documentation burden that results in clinician burnout. The American Medical Informatics Association (AMIA) is leading the 25x5 Symposium call-to-action national goal to reduce clinician documentation burden on U.S. clinicians to 25% by 2025.

In the 2021 Nursing Staff Wellbeing Survey completed by 1,212 nurses at a large, public academic health system, reducing the burden of documentation was among the top 3 recommendations to create a healthier work environment.

Six Domains of Documentation Burden

The American Nursing Informatics Association (ANIA) built a framework showcasing six major domains contributing to the overall burden of EHR documentation. Each field has several areas of overlap and applies to most healthcare settings. It's essential to recognize that no single entity can independently resolve this issue. Multiple stakeholders must work in partnership to achieve a future state of EHR documentation that is patient-centric and user-friendly.
Source: ANIA Six Domains of Burden


"EHRs don't follow evidence-based usability and human factors design principles. Instead, the design was based on historical paper records, which led to extra time spent scrolling, clicking, and searching for information."


"Payors (such as CMS, Blue Cross, and Anthem) require specific documentation, administrative charting, and coding for reimbursement."


"There are documentation requirements reinforced by accreditation agencies (such as Joint Commission, Stroke Program Certifications, and State Regulatory Agencies)."


"Poor configuration of the internal and external structures results in duplication and re-entry of data that already exists in the electronic system."


"Regulatory agencies such as NDNQI (National Database of Nursing Quality Indicators), healthcare organizations, and the government require documentation demonstrating quality patient care was met."


"Organizational culture's influence on what should be documented can exceed what is essential for patient care, including:
  • Fear of litigation
  • "We've always done it this way"
  • Misinterpretation of regulatory standards
  • Special interest groups add documentation by clinicians to meet their needs"

Project Scope

Our core team consisted of four nursing informatics (NI) fellows and mentors from the NI team at a large, public academic health system. Each fellow pursued a different area of documentation, and my focus was on the Daily Cares and Safety (DCS) flowsheet.

This flowsheet promotes regular rounding by nurses and care partners to meet patient needs, including safety, mobility, hygiene, and nutrition. In each standard 12-hour shift, it's the shared responsibility of nurses and care partners to document each hour (using 24-hour military time) within DCS.

Day shift nurses document every two hours: 0800, 1000, 1200, 1400, 1600, and 1800. Similarly, night shift nurses chart under these times: 2000, 2200, 0000, 0200, 0400, and 0600. Meanwhile, care partners document under all the odd hours.

The 22 units in scope include all inpatient, adult medical-surgical, and intensive care floors at UCLA Health. A significant variance in the documentation excluded specialty areas such as pediatrics, OB, PACU, and ED.
Adult Medical Surgical (Med/Surg) Daily Cares Flowsheet
Adult Intensive Care Unit (ICU) Daily Cares Flowsheet
  • Emergency Department (ED)
  • Post-Anesthesia Care Unit (PACU)
  • Obstetrics (OB)
  • Pediatrics

Inclusion Criteria

An inclusion criterion was formulated to standardize the approach to examining nursing documentation for its purpose and usefulness. The criteria included:
Required to provide care to the patient and accessed by other care team members and/or by the patient.
Non-duplicative, relevant and value added.
Mandated by policy, regulatory, compliance, reimbursement or external reporting mandates.
Triggers an action to another care team member.
Necessary to document that patient refused ordered care.
Information that does not meet any of the inclusion criteria will go through governance review for deletion.

Project Goals


Develop Guiding Principles and Inclusion Criteria for nursing documentation.


Increase the amount of time nurses have to spend with the patients.


Increase nurse efficiency and effectiveness.


Standardize documentation across nursing units.


Decrease redundant and minimally used flowsheet rows and choices list options.


Increase usability by decreasing clicks, scrolling, screen flips and free text comments.


Enhance patient experience and improve clinician well-being.


The Process

Project Phases

Usability and human factors design principles rooted in human-computer interaction (HCI) were applied: to reduce cognitive load, use familiar patterns, and match between the system and the real world.
Source: AdobeXD Human Factors /Source: NNG Usability Heuristics
Since this initiative would impact many direct and indirect users, multiple stakeholders were consulted to review and suggest recommendations for the proposed changes. The feedback from end users contributed to many iterations before the final implementation.
Conducted content audit of all rows and choice list options within the Daily Cares and Safety flowsheet.

Identified areas of opportunity and all relevant stakeholders. Evaluated the feasibility of changes within the software limitations of EPIC.

Analyzed and refined the content with Subject Matter Experts (SME) and Clinical Nurse Specialists (CNS).
Multiple governance councils were involved in providing feedback on the value of the content and proposed changes.
Approaches taken to increase usability:
  • Eliminated duplications
  • Relocated content
  • Refined language to provide consistency
  • Condensed flowsheet rows and choice lists
Application analysts created mock-up builds with proposed changes in EPIC's playground software tool that don't interfere with actual patient medical records.
Developed educational tip sheets for all final changes with training specialists.
The Workflow Analyzer tool was used to measure the impact of the final changes.


Baseline Data

Baseline Data
Time Spent in Flowsheets
(August 2021)
ICU Units
84 mins per 12hr shift per nurse
Med/Surg Units
69 mins per 12hr shift per nurse

Nurses & Care Partner Rounding

  • Surveyed 130 nurses across a large, public academic health system.
  • Direct feedback given from nursing rounds.
  • Care partner rounding revealed gaps in communicating patient mobility levels.
Redundant documentation and unnecessary charting taking away from patient care."

What Nurses Are Saying

Patient mobility charting, charting in 3 different places. Would be easier and faster if I could chart in one column.”
Double charting. There are still many places we’re documenting the same thing.”


Content Audit, Analysis, Iterations

Daily Cares/ Safety Flowsheet Content Audit
The two most utilized sections: (1) 'Safety' and (2) 'Mobility/ Equipment' were selected for an in-depth analysis of its rows and choice list options to determine opportunities for improvement.

Rows are the data fields located within each section. Choice list options are the selections available in each row. Some of the approaches taken to assess content utility were:
Content Analysis and Iterations
Stakeholder expertise and feedback were used to iterate on suggested design changes.

Subject Matter Experts

Subject matter experts and clinical nurse specialists were consulted to ensure changes were aligned with policy and best practice guidelines. These specialties included:
  • Wound Care/ Pressure Injury Prevention
  • Fall Prevention
  • Mobility
  • Workplace Safety
  • Restraints

Bedside Nurses

Clinical bedside nurses from the New Knowledge & Innovation nursing professional governance council provided feedback as the end users of this documentation.

Nurse Managers & Educators

Nurse managers and educators in the Nursing Prioritization council, who oversees CareConnect optimization requests were consulted. They provided critical input as content auditors that track data across monthly reports.

Quality & Risk Management

The risk management and quality experts were consulted to review proposed changes to uphold all regulatory expectations.


Final Designs

Redesigning Safety & Mobility Rows

The rows within the 'Safety' category primarily captured various fall prevention measures to ensure patient safety. Therefore, the rows that didn't add value to this purpose were relocated to a more relevant category.

Regarding the 'Mobility/ Equipment' category, the main objective of these rows was to communicate the level of assistance and any supportive equipment required to mobilize the patient safely. The following changes were made:
  • ‍Within 'Safety' the row "Transport Method"was deleted
    Patient transport information was communicated between nurses and staff through phone instead.
  • Within 'Mobility/ Equipment,' the rows "Position" and "Range of Motion" were deleted due to repeated information found in other areas.
  • The row "Duration (min)" was rarely used based on the low frequency shown in the quantitive analysis.



Excessive wording. Repetitive terms. "Sitter" = "Constant Observation Aide"
Rows moved from 'SAFETY' category to 'MOBILITY/ EQUIPMENT' to best reflect the purpose of documentation.
Deleted rows that are non-value added and containing redundant information.
Updated to current evidence-based practice. Streamlined to present mobility information in one place.

Redesigning Safety & Mobility Choice Lists

The choice list options within each row were analyzed to determine relevance, best terminology, and organization to minimize cognitive load.  

Before & after

Before & after

Relocation of Bedside Mobility Assessment Tool (B.M.A.T.)

Based on the nurses' feedback, mobility charting was redundant, nonessential, and observed in multiple rows and flowsheets. Some of the factors that led to this issue were:
  • Adding new mobility documentation without removing previously used rows and choice lists.
  • Expectations for mobility charting existed in both the 'Assessment' flowsheet and the 'DCS' flowsheet. The difference was that the 'Assessment' flowsheet reflected current best practices, while 'DCS' had an outdated version.
  • The row within the BMAT assessment labeled "Is patient able to participate in BMAT?" with the responses "Yes" or "No" were deemed to be non-value added.
  • The patient's BMAT level can change due to fatigue or changes in clinical condition. Therefore, this row was most appropriate in a flowsheet area regularly updated multiple times a shift, like the DCS.



Integration of Restraints Documentation

When patients are placed in restraints, nurses are expected to monitor and document restraints every two hours. It's closely examined by auditors and strictly mandated by regulatory bodies such as the Joint Commission.

Due to the sensitive nature of restraints, there are documentation fall-out review groups and a restraint SME who audits patient charts for missed documentation.
  • The majority of missed documentation occurred in the last few hours of the shift. Nurses reported it was a challenge to remember to return to a separate "Restraints" flowsheet.
  • The restraints documentation workflow analysis revealed unavoidable extra steps to manually search and select the appropriate flowsheet to begin charting.
  • As a result, a new row labeled "Restraints Documentation" was added to the "DCS" flowsheet. This change helped eliminate extra steps and streamline charting both 'Restraints' and 'DCS' every two hours in one place.




The Impact

Impact of Changes

With nearly 4,000 registered nurses at this large, public academic health system, many of whom are bedside nurses working on the 22 units affected by this project.

This table represents a quantitative overview of the changes made to the number of rows and the number of choice lists in three categories: 'Safety,' 'Mobility/Equipment,' and 'Safe Patient Handling.'

Although 'Safe Patient Handling' was located in another flowsheet, it was relevant to mobility documentation. In this section, multiple pediatric-specific choice lists were hidden from units with an adult population.

Workflow Analyzer Tool: Safety & Mobility Documentation

Epic is a cloud-based EHR built for hospitals where healthcare professionals access patient medical records. An Epic-provided program called the Workflow Analyzer Tool measured the calculated task duration, number of transitions, and number of actions after analyzing each step in a given workflow.

In one standard 12-hour shift, nurses chart at least every two hours and, thus, at least six times in the 'Safety' and 'Mobility/Equipment' sections of the 'DCS' flowsheet.

The results below represent one column of 'Safety' and 'Mobility/Equipment' documentation equivalent to 1 out of 6 minimum occurrences within one shift. Two workflows were examined: one before, and one after changes were implemented. The results indicated:
  • Calculated Task Duration: Difference suggests the new workflow is more efficient.
  • Transitions: Zero change noted here.
  • Actions: A 40% reduction in total number of mouse clicks and keypresses seen in the new workflow.



Workflow Analyzer Tool: Restraints Documentation

The results below represent the 'Restraints' documentation for an entire 12-hour shift. "Restraint Monitoring" is charted every two hours, and the flowsheet is accessed three different times to simulate clinical practice.

Two workflows were examined: one before, and one after changes were implemented. The Workflow Analyzer tool analysis demonstrated:
  • Calculated Task Duration: Small difference noted.
  • Transitions: Nearly 95% reduction seen in screen changes with the new workflow.
  • Actions: About 90% decrease in total number of mouse clicks and keypresses revealed in the new workflow.




Project Takeaways

Project Takeaways

  • A) When undertaking a system-wide initiative, many stakeholders need to be included in the process and regularly updated.
  • B) There is a mixed understanding of what needs to be documented amongst stakeholders leading to over-documentation.
  • C) It can be challenging to reach a consensus when seeking approval from various specialty departments, subject matter experts, and professional governance councils.
  • D) There was no identified “owner” of nursing documentation. As you can imagine, there were gaps in oversight in challenging best practices in documentation.
  • E) Although documentation regarded as 'standards of care' were initially proposed for removal, the Risk and Regulatory teams recommended against it.
  • F) Nurse leaders were auditing and tracking specific rows behind-the-scenes to generate monthly reports for review.
  • G) There are limitations within Epic's CareConnect EHR build that prevent some stakeholder feedback from being applied.
  • H) In the final build stage before implementation, analysts discovered rows encoded as part of an algorithm for a new automated tool. Thus, leading to a setback for some changes.