The Daily Balancing Act for Nurses: Paperwork vs. Patient Care

Lynette Jones, RN, PhD, MBA
nVoq Industry Advisor

Nurses today are expected to capture a tremendous amount of information during each shift, whether working on a hospital floor or in other clinical and residential settings. While much of this data needs to be formally recorded in the patient’s EMR, there are also general observations of interest to incoming staff covering the same patients.  Using a pocket notebook, “sticky notes” or oral communication to transmit this information is a regular practice among the nursing community.  With escalating reporting requirements, it’s estimated that nurses are spending 25-30% or more of their daily shift on documentation – reducing the time they can spend on patient care.

Until recently, the cost and complexity of speech recognition technology has prevented it from being deployed on a widespread basis in the hospital – it is usually just targeted at physicians.  SayIt™ changes that paradigm by making speech recognition affordable, easy to use and easy for the nursing community to implement.

SayIt allows nurses to chart notes directly into an electronic medical record (EMR) or capture observations made during the shift for review with incoming personnel. SayIt can easily be configured to understand individual voice patterns and custom vocabulary like proper names and abbreviations. Short voice commands can be used to navigate EMR templates, insert rote text blocks and edit dictations – minimizing keystrokes and time at the keyboard vs. at the bedside.

With SayIt, nurses do not have to be tethered to a computer. Where WiFi is available, SayIt allows the nurse to roam around patient’s room while dictating. This also leaves the nurse’s hands free to perform patient care. Mobile devices including the iPhone, iPod™, iPad and other tablets are used to capture information that can be stored and forwarded to other team members, or available for use within the EMR. SayIt also works with PCs and other traditional workstations. It’s web-based, so the nurse can use it with any device they wish without having to install software each time.

Benefits of SayIt for the Nursing Community

• SayIt is a boon to nurses with minimal keyboard skills. Dictation can be used with or without a keyboard to augment documentation. SayIt can be programmed so that terms spoken in popular clinical parlance are spelled out correctly in the record. For example, when a nurse says “O2 Sats,” SayIt puts in the full term, “oxygen saturation.” Complex phrases such as “autonomic dysreflexia” can be dictated by the user with the assurance that SayIt will spell it correctly in the record. This also applies to brand names for prescription drugs.
• SayIt speeds up documentation in a number of ways. Dictating the phrase “VS normal” can input the text “vital signs within normal range” into the nursing notes. Hence, notes several lines long are quickly documented with correct spelling and enforcement of standardized terminology. SayIt can also be configured so that a spoken word can add checkmarks to one or more boxes in standardized forms.
• SayIt can be configured to ensure that nurses use only approved abbreviations. This facilitates compliance with the Joint Commission requirement that health care organizations develop and adhere to a standardized list of abbreviated terms.
• Nurses can utilize SayIt to both support and translate standardized nursing taxonomies such as the International Classification of Nursing Practice (ICNP).  A nurse can say “Self-Care Deficit” and SayIt recognition will translate it into the full ICNP knowledge term “Actual negative ability to perform self-care activities.” The knowledge term can then be automatically coded for billing of nursing services. This is particularly important for nursing practices that bill independently, such as home health.
• Health care data is often analyzed by physician, but as any clinical informaticist will tell you, the validity of such information is affected by all the different ways that physician names are entered into a medical record. Dr. Bob Jones can be entered as Dr. B. Jones, Dr. Robert Jones, Dr. R. Jones, or all three, within the same patient record. Speech recognition helps standardize input into structured fields. For example, when a nurse says “Dr. Bob Jones,” SayIt will automatically process this as the organization’s preferred term “Dr. Robert Jones.” This improves billing cycles and ultimately, cash flow, for health care organizations.
• Since the ICNP is mapped to SNOMED and compliant with HL7 data transmission standards, nursing terminologies can be used for statistical analyses of nursing’s contribution to the health care team and patient outcomes.

With SayIt, speech recognition is no longer just for doctors. To see SayIt in action, please join me and the nVoq team at the American Organization of Nurse Executives’ Annual Expo, Booth #205, March 22-23 at the Hynes Conference Center in Boston.