For centuries nurses have been documenting the day to day activities and interventions of their patients. A well-crafted nurses note is a work of art, not only conveying the important information regarding their patient’s health status and response to treatment but also setting a tone and telling “the patient story.”
What does it take to be a fantastic nurse? Many wonder if they have what it takes to excel in the nursing profession. There are some key differences between an average nurse and a fantastic nurse. If you’re smart enough and dedicated enough, nearly anyone can become an average nurse. But it takes a certain something to elevate yourself to the fantastic level.
Many people do not realize there are differences between an electronic medical record (EMR), electronic health record (EHR), and a personal health record (PHR). I myself am guilty of often using the terms EHR and EMR interchangeably. There are, however, some defining differences that set these health and medical records apart.
As nurses we are given such trust and responsibility. Often people’s lives are in our hands. We a allowed to care for people in their most vulnerable states. And depending on your license level, becoming a nurse is as simple as completing a couple years in tech school and pass a computerized test. Somehow in that short amount of time and with a few electronic questions a computer screen, we are deemed competent to be a nurse.
That’s what nursing informatiics is like. Or at least, in my humble opinion, that’s how nurse informaticists should practice. We can’t fix immediate problems and ignore the big picture. By all means, we must fix the immediate issues, but we need to explore and dig deeper to see what really caused the problem and how we can not only fix this problem, but improve the entire process.
Continuity of care documents (CCD) are a standard in electronic charting which ensures that relevant protected health information (PHI) can be shared with providers electronically and be received and used in a meaningful way.
You expect a nurse to have integrity and use good clinical judgement, but not every one does. It’s even possible that not everyone can. Judgement is subjective, and even though the it is the goal for any prudent nurse to give the same level of care as another, it just doesn’t always happen that way.
Clinical Informatics (working behind the scenes with documentation and software) is such a fantastic combination of my learned skills, natural attributes, and passions. Heck, I even called myself a Nerdy Nurse for a full year before I even was one… well I was nerdy, and a nurse, but the two paths didn’t merge as often as I would have liked… but I digress.
If you aren’t as nerdy of a nurse as I, then you may not appreciate the innovations that they are making in EMR and hospital apps. You may not get excited and admire the beauty of the clean lines, colors, and images that are presented. And I get that. I don’t understand your obsession with you dog or car, so I get you don’t see the same things I do in technology.