I have reviewed thousands of medical records for identification of key facts, issues, and deviations from the standard of care, in the more than two decades I have been a nurse. For example:
- As a critical care nurse who worked in several different departments, I studied and interpreted ER notes, physicians’ history and physical reports, physicians’ consult reports, operative reports, radiology results, procedure notes, lab tests, and medical records from other facilities to coordinate the appropriate care for patients and to facilitate the care across the patient care continuum.
- As a charge/lead nurse, I created documentation reports. As well, I audited innumerable nurses’ charting documents for deviations and adherence to hospital and agency policies and federal regulations.
- As a travel nurse, I was able to work with many different electronic health record systems.