Technology and Documentation Caregivers Perform Essential Services in Healthcare Delivery

In healthcare, all caregiver roles are important – from those on the front lines to those behind the scenes. Among healthcare’s unsung heroes are technology management professionals and documentation specialists.

In honor of Healthcare Technology Management Week and Healthcare Documentation Integrity Week, Cleveland Clinic’s Caregiver Office recognizes those who manage and maintain today’s health technologies, as well as the dedicated documentation specialists who ensure complete and accurate clinical documentation and data capture.

Carolyn Wright, BSN, RN, Clinical Systems Analyst, and Ashley Fuerte, MSN, RN, Clinical Documentation Improvement Specialist, share insights into their careers in these rewarding professions.

Creating a new inpatient Epic application

Wright was hired to help build and integrate into practice a new inpatient Epic application that allows patients to review aspects of their current hospitalization via their mobile device. Patients can see members of their treatment team, including photos, review labs and test results, watch educational videos assigned to them by the nursing staff and more. “We perform a lot of testing in every environment to ensure all technologies are working as expected before they are put into production,” Wright says.

Before taking on her new position in May 2020, Wright had been a registered nurse in a variety of clinical environments.

“I always enjoyed learning about the functionality of Epic and wanted a new career challenge,” she says. “As a clinical analyst, I felt I would be presented with a different way to help clinicians and patients, and accepting this position has been one of my best career decisions. Given my nursing background, I bring a unique perspective to the clinical aspect of IT and am still able to interact with patients and support them on their wellness journey.”

IT is critical in healthcare because it can improve efficiency and effectiveness. During the pandemic, IT has played a significant role by enabling services such as virtual appointments and allowing patients to use mobile devices for appointment check-in. “I love the fact that my role involves helping a patient turn on the missing link to becoming more involved in their care,” Wright says.

“In any IT position, it’s important to prioritize, manage your time and ask questions,” Wright says. “My best advice is to listen, learn from others and work closely with end-users and other IT professionals. My team works very well together, and we have excellent leaders who are involved and supportive.”

The challenging ‘detective work’ of clinical documentation

As a CDI specialist, Fuerte works to improve clinical documentation by ensuring it is captured at the greatest diagnostic specificity through review of records, queries and provider education.

“What I like most about my job is that it’s intellectually challenging,” Fuerte says. “Every record I read is different and, in a sense, allows me to incorporate some detective work to ensure everything is documented to the most accurate degree. A typical day for me includes reviewing queries or questions I’ve previously submitted to physicians, checking for any new query requests from medical coders and reviewing new patient medical records.”

Fuerte began her CDI specialist career in February 2020 after spending 10 years as a registered nurse. She earned her master’s degree in nursing informatics.

“I feel that having a strong clinical background is invaluable in this role, and appreciate that I can use my clinical background, knowledge and experience to support myself in my position,” she says.

Fuerte is gratified that through their work with documentation, she, her managers and colleagues are able to contribute to Cleveland Clinic’s commitment to provide patients and communities with superior healthcare. Her advice to others considering a career in healthcare documentation: “You need to be flexible, willing to learn new things and open to change as the field is always evolving,” she says.

Celebrate technology management professionals and documentation specialists

Join us in recognizing and thanking today’s technology management and documentation specialists! Learn more about Cleveland Clinic opportunities in these fields.