READS: the rapid electronic assessment documentation system.

Abstract

Patient documentation is time consuming and can detract from care. The authors report a novel computer programme that manipulates routinely collected information to quantify nursing workload, along with the reason for admission, functional status, estimates of in-hospital mortality and life expectancy. The programme stores information in a database, and produces a print-out in a situation/background/assessment/recommendation (SBAR) format. The average time taken to enter 629 patient encounters was 6.6 minutes. Pain was the most common presentation for low workload patients, while high workload patients often presented with altered mental status and reduced mobility. There was only a modest correlation between the risk of death and nursing workload. The programme measures nursing workload without further paperwork, and improves routine documentation with a legible brief report that is automatically generated. This report can be shared and provides data that is immediately available for day-to-day care, audit, quality control and service planning.