Competencies: Nuts and Bolts

Abstract

Nurses are expected to provide safe, competent, and compassionate care in an increasingly technical and digital environment. Since the landmark 1999 Institute of Medicine (IOM) report To Error is Human,¹ health care professionals and consumers have been inundated with follow-up IOM reports,^2-5 popular press, and clear visibility of broken health care systems fraught with errors and need for transformation. Information and communication technologies have been identified as core prescriptions for addressing safety and quality. Nurses are directly engaged with information systems and technologies as the foundation for evidence-based practice, clinical decision support tools, and the electronic health record (EHR).

Appendices

Appendix

Clinical Information Management Competencies

TICC has transformed the Direct Care components of the HL7 EHR System Functional Model into recommended Clinical Information Management Competencies for nurses as shown below.

Using an EHRS, the nurse can:

• Identify and Maintain a Patient Record

• Manage Patient Demographics

• Capture Data and Documentation from External Clinical Sources

• Capture Patient-Originated Data

• Capture Patient Health Data Derived from Administrative Data

• Interact with Financial Data and Documentation

• Produce a Summary Record of Care

• Present Ad Hoc Views of the Health Record

• Manage Patient History

• Manage Patient and Family Preferences

• Manage Patient Advance Directives

• Manage Consents and Authorizations

• Manage Allergy, Intolerance, and Adverse Reaction Lists

• Manage Medication Lists

• Manage Problem Lists

• Manage Immunization Lists

• Interact with Guidelines and Protocols for Planning Care

• Manage Patient-Specific Care and Treatment Plans

• Manage Medication Orders as Appropriate for His/Her Scope of Practice

• Manage Nonmedication Patient Care Orders

• Manage Orders for Diagnostic Tests

• Manage Orders for Blood Products and Other Biologics

• Manage Referrals

• Manage Order Sets

• Manage Medication Administration

• Manage Immunization Administration

• Manage Results

• Manage Patient Clinical Measurements

• Manage Clinical Documents and Notes

• Manage Documentation of Clinician Response to Decision Support Prompts

• Generate and Record Patient-Specific Instructions

• Manage Health Information to Provide Decision Support for Standard Assessments

• Manage Health Information to Provide Decision Support for Patient Context-Driven assessments

• Manage Health Information to Provide Decision Support for Identification of Potential Problems and Trends

• Manage Health Information to Provide Decision Support for Patient and Family Preferences

• Interact with Decision Support for Standard Care Plans, Guidelines, and Protocols

• Interact with Decision Support for Context-Sensitive Care Plans, Guidelines, and Protocols

• Manage Health Information to Provide Decision Support Consistent Healthcare Management of Patient Groups or Populations

• Manage Health Information to Provide Decision Support for Research Protocols Relative to Individual Patient Care

• Manage Health Information to Provide Decision Support for Self-Care

• Interact with Decision Support for Medication and Immunization Ordering as Appropriate for His/Her Scope of Practice

• Interact with Decision Support for Drug Interaction Checking

• Interact with Decision Support for Patient-Specific Dosing and Warnings

• Interact with Decision Support for Medication Recommendations

• Interact with Decision Support for Medication and Immunization Administration

• Interact with Decision Support for Nonmedication Ordering

• Interact with Decision Support for Result Interpretation

• Interact with Decision Support for Referral Process

• Interact with Decision Support for Referral Recommendations

• Interact with Decision Support for Safe Blood Administration

• Interact with Decision Support for Accurate Specimen Collection

• Interact with Decision Support that Presents Alerts for Preventive Services and Wellness

• Interact with Decision Support for Notifications and Reminders for Preventive Services and Wellness

• Manage Health Information to Provide Decision Support for Epidemiological Investigations of Clinical Health Within a Population.

• Manage Health Information to Provide Decision Support for Notification and Response regarding Population Health Issues

• Manage Health Information to Provide Decision Support for Monitoring Response Notifications Regarding a Specific Patient’s Health

• Access Healthcare Guidance

• Interact with Clinical Workflow Tasking

• Interact with Clinical Task Assignment and Routing

• Interact with Clinical Task Linking

• Interact with Clinical Task Tracking

• Facilitate Interprovider Communication

• Facilitate Provider-Pharmacy Communication

• Facilitate Communications between Provider and Patient and/or the Patient Representative

• Facilitate Patient, Family, and Care Giver Education

• Facilitate Communication with Medical Devices

The above list comes from the Direct Care components of the HL7 EHR System Functional Model. In some cases functional statements were not changed as they can also serve as competencies. For example, the HL7 EHR System Functional Model statement of “Access Healthcare Guidance” was unchanged, except for the preamble that applies to all Clinical Information Management Competencies as “Using an EHRS, the nurse can: Access Healthcare Guidance.” The HL7 EHR System Functional Model statement of Communication with Medical Devices was changed from “Communication with Medical Devices” to “Facilitate Communication with Medical Devices” to make it a Clinical Information Management Competency.