I have worked in many different healthcare settings such as an emergency room, specialty,
primary care, hospital, and micro-hospital. My current role at the Veterans Healthcare as a
medical support assistant, I see the many roles a nurse plays within the organization. The
technology in the various facilities I’ve worked used similar but different software to
complete daily functions. The functions of the clinical nurse of an outpatient facility can
have different functions than an inpatient nurse. There are also different levels of nurses
certified, licensed, registered and nurse practitioners which all have different
responsibilities within the clinical setting. A nurse will always work in one department for
example a nurse who is working in a surgical unit will always work in that unit and her
responsibilities will differ from a nurse who is assigned to the pediatric unit. Different
nursing job role require different functions and how they use the clinical software for
documentation which allows them to have a access to different parts of the software. The
impact that it has on managing information can depend on the nurse roles and
responsibilities they carry daily. One aspect that is not really mentioned or talked about is
errors when managing and documenting, nurses are human, and mistakes are bound to
happen for example at the end of a long shift. How is that managed and how does one
correct the error?
Different organizations handle mistakes differently according to the healthcare information
management team. I’ve seen in some settings where the nurse made a simple addendum to
documentation and other facilities that require nurses to submit a ticket to fix errors. Either
way the management system in place is used to provide accurate and up to date
information to other provider who have access to the patients files.
Kaipio, J., Kuusisto, A., Hypponen, H., Heponiemi, T., Laaveri, T. (February 2020)
International Journal of Medical Informatics. Volume 134. Science Direct
