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 have 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 podiatric 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 have 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.
In my experience technology in the healthcare industry is different no matter where you go. For
example, from 2012 until 2019 I worked for a major healthcare organization, since I started, we
have been using one program with enhancements rolling out almost three times a year. e In 2016,
we were introduced to a new platform which was supposed to be newer and more improved than
the previous. I have to say that I was impressed and it was great! In 2019, we were bought out by
another managed healthcare organization who then introduced the company into a completely
new platform. All these platforms were meant to be able to serve the members/patients the best
of our abilities. We do have nurses who review medical records and serve members in a
completely different manner than that of nurses in a hospital setting. In a health insurance
company, our nurses are not providing bedside care per say. But they can review medical records
and make recommendations regarding their care without having that one-on-one time with the
member/patient. Whereas in a hospital setting, nurses are using technology to chart their
interactions with the patient. Whether it be for medication disbursement or vitals taken
throughout the day. Documenting the type of mental state, the patient is in, if they ate, what type
of diet they may be on. All things done based on bedside care. Yet in a primary care providers
office a nurse may be able to go more in depth into medical records because they may have more
time and provided one on one treatment.
Managing information can face challenges since not all entities use the same programs. Since all
organizations/providers and/facilities use different programs, managing medical records can face
some challenges and here is why; if a patient is being treated for Cancer at Moffit Cancer Centre
and choses to be part of a clinical trial at Florida Cancer institute, the patient is now at the mercy
of either one of the facilities to get the medical records from one to the other in time to make the
sound decision on treatment for the trial.
For example, a cancer registrar in a healthcare facility would require training on not only how to
manage registration for cancer patients within the facility database but they will also need to know
how to manage the cancer registry with the CTR (Certified Tumor Registrar) and the NCRA
(National Cancer Registrars Association). The CTR and NCRA are large databases which require
those managing or having access to it have proper training and utilize appropriately. (Bowie &
Green, 2018).
References
Bowie, M. J., & Green, M. A. (2018). Essentials of health information management: Principles and
practices. Cengage Learning.
Kaipio, J., Kuusisto, A., Hypponen, H., Heponiemi, T., Laaveri, T. (February 2020) International
Journal of Medical Informatics. Volume 134. Science Direct
