Posted
February 11, 2025

Real-time Documentation with Voice Charting for Nurses

Voice charting on the go is key to giving nurses back control of their day.

Voice charting on the go is key to giving nurses back control of their day.

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Voice charting on the go is key to giving nurses back control of their day.

Voice charting on the go is key to giving nurses back control of their day.

By Kathleen Harmon (MS, RN), Aiva Health Clinical Innovation Lead

"[V]oice-enabled, real-time documentation is the best solution to improve accuracy and timeliness of nurse documentation."

- Melissa Breth (DNP, RN, NI-BC) nursing informatics leader, Breth Consulting.

By Kathleen Harmon (MS, RN), Aiva Health Clinical Innovation Lead

"[V]oice-enabled, real-time documentation is the best solution to improve accuracy and timeliness of nurse documentation."

- Melissa Breth (DNP, RN, NI-BC) nursing informatics leader, Breth Consulting.

For nurses, cognitive burden and administrative workload is at an all-time high.  This is contributing to nursing dissatisfaction and high turnover rates.  At a time when nurses are in such high demand, this must be addressed.  


Thinking back 38 years when I became a registered nurse, the cognitive burden was also very high, relying on nurse dispensed medications (prior to unit dose)and treating patients in 4 or more bed wards, all with written notes and deciphering physician orders, the stress level for nurses was not sustainable.  Fast forward to the implementation of the electronic medical record (EMR) and other technologies that support care delivery, we’ve removed a large portion of risk, but have we moved the pendulum too far?  Are nurses interacting with technology more than with their patients?

Nurses spend on average over 40% of their shift interacting with the EMR, and in speaking to CNIO’s across the country, some say the percentage is much higher.  Add the additional technology in the care environment including dietary, translation services, nurse call, and education systems that nurses interact with during their shift, it’s clear to see how we’re back to a work environment that is not sustainable.  

By Kathleen Harmon (MS, RN), Aiva Health Clinical Innovation Lead

"[V]oice-enabled, real-time documentation is the best solution to improve accuracy and timeliness of nurse documentation."

- Melissa Breth (DNP, RN, NI-BC) nursing informatics leader, Breth Consulting.

By Kathleen Harmon (MS, RN), Aiva Health Clinical Innovation Lead

"[V]oice-enabled, real-time documentation is the best solution to improve accuracy and timeliness of nurse documentation."

- Melissa Breth (DNP, RN, NI-BC) nursing informatics leader, Breth Consulting.

Real time documentation via voice enablement is necessary to address this challenge.  However, we cannot deploy the same functionality as we have for providers and expect it to work for nursing.  Provider workflow is significantly different and, for physicians, using voice to summarize an interaction and then approving and entering into the official record sometime after the encounter, is acceptable.  This is not leading practice for nurses.  Nurses should document real-time, meaning voice enablement is reviewed and approved by the nurse in real-time and is entered into the appropriate field within the EMR. 

Real time documentation via voice enablement is necessary to address this challenge.  However, we cannot deploy the same functionality as we have for providers and expect it to work for nursing.  Provider workflow is significantly different and, for physicians, using voice to summarize an interaction and then approving and entering into the official record sometime after the encounter, is acceptable.  This is not leading practice for nurses.  Nurses should document real-time, meaning voice enablement is reviewed and approved by the nurse in real-time and is entered into the appropriate field within the EMR. 

Real time documentation via voice enablement is necessary to address this challenge.  However, we cannot deploy the same functionality as we have for providers and expect it to work for nursing.  Provider workflow is significantly different and, for physicians, using voice to summarize an interaction and then approving and entering into the official record sometime after the encounter, is acceptable.  This is not leading practice for nurses.  Nurses should document real-time, meaning voice enablement is reviewed and approved by the nurse in real-time and is entered into the appropriate field within the EMR. 

Real time documentation via voice enablement is necessary to address this challenge.  However, we cannot deploy the same functionality as we have for providers and expect it to work for nursing.  Provider workflow is significantly different and, for physicians, using voice to summarize an interaction and then approving and entering into the official record sometime after the encounter, is acceptable.  This is not leading practice for nurses.  Nurses should document real-time, meaning voice enablement is reviewed and approved by the nurse in real-time and is entered into the appropriate field within the EMR. 

Contributing to this topic, Melissa Breth, DNP, RN, NI-BC, nursing informatics leader and founder of Breth Consulting, states, “since transitioning to the electronic health record (EHR), I'm pleased to see technological advancements that aim to streamline nursing workflow efficiencies while improving care quality and patient satisfaction. Studies continue to show that real-time documentation yields safer, more efficient nursing care such as one by Jepsen, Hellerup, & Specht (2022). Just as mobile health applications present the potential for decreased fragmented and disrupted documentation workflows (Ehrler et al., 2021), voice-enabled, real-time documentation is the best solution to improve accuracy and timeliness of nurse documentation. This is imperative for improved data integrity for data-driven healthcare that supports value-based care, precision health, and the likely future incorporation of AI. A recent study that simulated this technology was well-received by the nurse participants (Mayer et al., 2022). I'm excited to see voice-enabled documentation for nurses roll out in practice.”

Contributing to this topic, Melissa Breth, DNP, RN, NI-BC, nursing informatics leader and founder of Breth Consulting, states, “since transitioning to the electronic health record (EHR), I'm pleased to see technological advancements that aim to streamline nursing workflow efficiencies while improving care quality and patient satisfaction. Studies continue to show that real-time documentation yields safer, more efficient nursing care such as one by Jepsen, Hellerup, & Specht (2022). Just as mobile health applications present the potential for decreased fragmented and disrupted documentation workflows (Ehrler et al., 2021), voice-enabled, real-time documentation is the best solution to improve accuracy and timeliness of nurse documentation. This is imperative for improved data integrity for data-driven healthcare that supports value-based care, precision health, and the likely future incorporation of AI. A recent study that simulated this technology was well-received by the nurse participants (Mayer et al., 2022). I'm excited to see voice-enabled documentation for nurses roll out in practice.”

Contributing to this topic, Melissa Breth, DNP, RN, NI-BC, nursing informatics leader and founder of Breth Consulting, states, “since transitioning to the electronic health record (EHR), I'm pleased to see technological advancements that aim to streamline nursing workflow efficiencies while improving care quality and patient satisfaction. Studies continue to show that real-time documentation yields safer, more efficient nursing care such as one by Jepsen, Hellerup, & Specht (2022). Just as mobile health applications present the potential for decreased fragmented and disrupted documentation workflows (Ehrler et al., 2021), voice-enabled, real-time documentation is the best solution to improve accuracy and timeliness of nurse documentation. This is imperative for improved data integrity for data-driven healthcare that supports value-based care, precision health, and the likely future incorporation of AI. A recent study that simulated this technology was well-received by the nurse participants (Mayer et al., 2022). I'm excited to see voice-enabled documentation for nurses roll out in practice.”

Contributing to this topic, Melissa Breth, DNP, RN, NI-BC, nursing informatics leader and founder of Breth Consulting, states, “since transitioning to the electronic health record (EHR), I'm pleased to see technological advancements that aim to streamline nursing workflow efficiencies while improving care quality and patient satisfaction. Studies continue to show that real-time documentation yields safer, more efficient nursing care such as one by Jepsen, Hellerup, & Specht (2022). Just as mobile health applications present the potential for decreased fragmented and disrupted documentation workflows (Ehrler et al., 2021), voice-enabled, real-time documentation is the best solution to improve accuracy and timeliness of nurse documentation. This is imperative for improved data integrity for data-driven healthcare that supports value-based care, precision health, and the likely future incorporation of AI. A recent study that simulated this technology was well-received by the nurse participants (Mayer et al., 2022). I'm excited to see voice-enabled documentation for nurses roll out in practice.”

The solution is Aiva’s Nurse Assistant.  This application is designed by nurses for nurses, and truly supports nursing practice.  It is the professional and personal assistant all nurses need, and early pilot groups are showing impressive adoption rates, improvement in timeliness to documentation, and enthusiastic nurse feedback.

 

The key benefit to this is that nurses can use conversational voice or text commands to document real-time to the flow sheet.   Think about it:  you're much more likely to document in real time because you don't have to sit down at a computer, log into the EMR, navigate to the right patient, sheets, rows and field and then log back out again for every observation.

Early adopters are tracking key outcomes including:

·   Improved quality:  real time documentation (reduced batched charting) allows the EMR to perform clinical decision support and identify early deterioration.  Patient information is instantly available to interdependent teams of providers at the point of care.

The solution is Aiva’s Nurse Assistant.  This application is designed by nurses for nurses, and truly supports nursing practice.  It is the professional and personal assistant all nurses need, and early pilot groups are showing impressive adoption rates, improvement in timeliness to documentation, and enthusiastic nurse feedback.

 

The key benefit to this is that nurses can use conversational voice or text commands to document real-time to the flow sheet.   Think about it:  you're much more likely to document in real time because you don't have to sit down at a computer, log into the EMR, navigate to the right patient, sheets, rows and field and then log back out again for every observation.

Early adopters are tracking key outcomes including:

·   Improved quality:  real time documentation (reduced batched charting) allows the EMR to perform clinical decision support and identify early deterioration.  Patient information is instantly available to interdependent teams of providers at the point of care.

·   Nurse Satisfaction:  self-set reminders and workflow prompts are customizable for individual practice, and manual entry is greatly reduced.  For example, charting that you repositioned a patient might take 30 seconds with voice vs 3 minutes with manual entry.

·   Financial impact:  overtime costs can be reduced since documentation is performed real-time rather than post-shift, and, longer-term, more satisfied nurses should result in lower turnover.

Upcoming Assistant functionality will include setting reminders for care interventions in a conversational manner, accessing EMR data and voice control of other systems like interpreter services, dietary, work orders and policies & procedures. These are all designed to provide more time for high-value activities like bedside care, but they should also contribute to more real-time documentation since nurses won't feel as crunched for time.

The solution is Aiva’s Nurse Assistant.  This application is designed by nurses for nurses, and truly supports nursing practice.  It is the professional and personal assistant all nurses need, and early pilot groups are showing impressive adoption rates, improvement in timeliness to documentation, and enthusiastic nurse feedback.

 

The key benefit to this is that nurses can use conversational voice or text commands to document real-time to the flow sheet.   Think about it:  you're much more likely to document in real time because you don't have to sit down at a computer, log into the EMR, navigate to the right patient, sheets, rows and field and then log back out again for every observation.

Early adopters are tracking key outcomes including:

·   Improved quality:  real time documentation (reduced batched charting) allows the EMR to perform clinical decision support and identify early deterioration.  Patient information is instantly available to interdependent teams of providers at the point of care.

The solution is Aiva’s Nurse Assistant.  This application is designed by nurses for nurses, and truly supports nursing practice.  It is the professional and personal assistant all nurses need, and early pilot groups are showing impressive adoption rates, improvement in timeliness to documentation, and enthusiastic nurse feedback.

 

The key benefit to this is that nurses can use conversational voice or text commands to document real-time to the flow sheet.   Think about it:  you're much more likely to document in real time because you don't have to sit down at a computer, log into the EMR, navigate to the right patient, sheets, rows and field and then log back out again for every observation.

Early adopters are tracking key outcomes including:

·   Improved quality:  real time documentation (reduced batched charting) allows the EMR to perform clinical decision support and identify early deterioration.  Patient information is instantly available to interdependent teams of providers at the point of care.

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