Table 1

Physician, Nurse, and Respiratory Therapist work definitions




Direct Care

Any activity directly related to patient care.

Admitting a patient

Examining/reviewing a patient

Performing medical procedures

Assisting other staff with procedure

Escorting a patient

Communicating with patient/relative

Taking a history

Medication related activities


Reviewing documentation/results

Planning care

Communicating with staff member

Note: All communication with patient/relative is defined as direct patient care. When the participant is discussing medications with a patient (e.g. as part of history taking and review), this is defined as a medication related event.

Indirect Care

Any activity indirectly related to patient care.

Reading & reviewing documents

Planning care and ordering tests, diet etc.

Running blood gases

Retrieving information (from temporary or perm record, or computer)

Checking results

Washing hands

Gathering & returning equipment

Cleaning up after a procedure

Watching monitors

Find medical record-drop down

Find x-ray/scan-drop down

Medication related activities

Documenting in patient notes

Communicating with staff member

Communicating with patient/relative

Note: Monitors, ventilators, and other electronic patient care equipment should be coded as 'computer'.


Any activity that relates to medication for a particular patient.

Medication: Find Order

Looking for medication charts

Looking for notes in general

Medication: Prescribe Drug

Writing up a new order

Changing orders

Receiving or requesting a verbal order

Giving a verbal order

Writing discharge scripts

Obtaining drug authority numbers

Re-writing orders (e.g. legibility issues, needs signatures, etc.) Following a request for clarification (see Clarify)

Medication: Transcribe Order

Copying med orders from one medication chart to new one (e.g. for end of week continuing meds)

Transcribing verbal order

Re-writing orders (e.g. legibility issues, needs signatures, etc.) following a request for clarification (see Clarify)

Medication: Prep Drug

Activity around drug preparation & clean-up

Reading medication order to select drug

Finding drug/or reconstitution fluid/or selection of appropriate equipment for preparation and administration

Locating drug keys

Preparing the drug (e.g. reconstitution, drawing up solution, crushing tablets, preparing nebulizers)

Commencement and removal of IV infusions, cannulation, rearranging and disconnecting tubing for the purpose of drug administration

Returning/disposing equipment &/or drug following administration

S4/S8 counting & drug register entry for individual patients

Checking the drug with other staff (when the participant who is being observed is responsible for the drug)

Faxing/scanning order to pharmacy

Re-ordering/re-filling drugs

Medication: Clarify

Action taken when:

Asked to clarify an order that has been previously written, or

asking another doctor to clarify an order; or Seeking drug information for clarification (e.g. when prescribing)

Re-writing a drug order due to illegibility or legal reasons (or asking a doctor to re-write)

Checking the particular drug details in Mims or other source

asking another health professional about the drug order

Clarifying with the patient about the drug order

Asking another nurse or doctor to check a drug that the observed participant wants to give (see Prep drug)

Medication: Check Drug

Checking with & co-signing of a nurse's or another doctor's medication

Witnessing any other medication for another health professional (e.g. IV a/b checks)

Checking ID band &/or order &/or label

Asking another nurse or doctor to check a drug that the participant wants to give (see Prep drug)

Medication: Administering/Charting

Giving medication to a patient/recording drug administration details

Any patient preparation (e.g. sitting patient up so they can swallow medication, etc.)

Reviewing &/or taking &/or documenting vital signs as part of the protocol before giving the medication (e.g. pulse prior to digoxin)

Checking &/or adjusting IV admin throughout the administration process (e.g. returning to the pt & checking tubing, drip rate, etc.)

Documenting on medication order notes

Silencing IV pumps

Co-signing (see check-drug)

Drug register (see Prep drug or Check drug)

Medication: Discuss

Talking about a drug with another health professional &/or patient/relative

Choice of drug &/or dosage

Side effects

Discharge education


Administration protocols

Clarification of an order (see Clarify)

Requests for re-writing of order due to illegibility (see Clarify)

Medication: Review

Looking over drug orders as part of planning care


Any recording of patient information on paper or computer.

Writing on temporary record (e.g. own list)

Writing in patients' notes

Getting physicians to sign-off on non-medication orders

Discharge summaries-drop down

Medication chart documentation

Professional Communication

Any work-related discussion with another staff member.

Requesting medical or nursing consult or review

Planning care with any health professional

Handover/parts of a ward round

Medication related discussion

Communication with patient/relative


Any administrative activity that is not related to direct or indirect individual patient care. Also includes activities that relate to the running of the unit in general (but aren't related to direct or indirect patient care).

Duty rosters

Employment issues

Bed allocations

Coordination of staff activities

Staff meetings (not case or clinical meetings)

Unit related

Unit orders for stock



In Transit

Work related movement between patients and between tasks.

Movement when the participant exits a patient room

Movement between patients in a shared room

Movement within a single room

Note: When the participant arrives at another task or patient, "In Transit" ceases and the next appropriate category is chosen for that active task.

e.g. participant leaves room to get equipment = in transit

participant returns with equipment = indirect care


Active supervision or teaching of another staff member or student.

Attending education sessions (e.g. grand rounds)

Note: When the participant is actively supervising, "supervision" is selected and all tasks normally undertaken by the participant are added under "multi".


Any social or personal activity or discussion.

Personal phone calls, tea & personal breaks

Bathroom breaks

Reading books/magazines


Whenever the participant's pager alerts, pager is to be entered as an interruption.

Reading pager

Returning call

Calling/having paged other healthcare providers (See Professional Communication)

Ballermann et al. BMC Medical Informatics and Decision Making 2011 11:32   doi:10.1186/1472-6947-11-32

Open Data