Nurse
You provide bedside and clinic care: recording observations, administering medication, and supporting the clinical team. Like the clinician, you are an ordering role for diagnostics — you raise orders, but you do not produce results.
What you can do
Section titled “What you can do”Your role (nurse) holds these capabilities:
- Document care — open encounters, write clinical notes, manage allergies, care plans, reminders and tasks. (
chart.encounter.create,chart.note.write,chart.allergy.manage,chart.careplan.manage,chart.task.manage) - Record vitals and administer medication. (
chart.vitals.record,chart.medication.administer) - Administer on the MAR — give, hold or refuse medication against the medication administration record. (
rx.mar.administer) - Order lab tests and imaging, and print specimen labels at the bedside. (
lab.order.create,lab.label.print,imaging.order.create) - Author and eSign referrals, read patient profiles and the master index. (
appointments.refer,register.read,patients.read) - On the floor: triage and treat in the ED, and provide nursing care and medication on the ward. (
ed.triage,ed.treat,ward.nurse,ward.medicate)
What you cannot do
Section titled “What you cannot do”You cannot prescribe (that is a clinician capability), nor enter/verify lab results, author imaging reports, or dispense. You administer medication that a clinician has prescribed; you do not author the prescription.
Where you work
Section titled “Where you work”| Screen | Module | What you do there |
|---|---|---|
| Patients, New Encounter | Chart | Document care, record vitals |
| Vitals Station | Queue | Capture observations in flow |
| Observations, Medication Administration | Ward | Inpatient obs and MAR |
| New Requisition | Diagnostics | Order labs + imaging |
A typical day
Section titled “A typical day”- At the Vitals Station, capture temperature, heart rate, blood pressure, SpO₂ and respiratory rate.
- Open the patient in Chart to write notes and update allergies or care plans.
- Raise lab and imaging orders from New Requisition when asked; print specimen labels at the bench.
- On the ward, record observations and administer medication on the MAR — mark each dose Given, Held or Refused.
Related guides
Section titled “Related guides”- See the dedicated Ward Nurse guide for inpatient duties.
- Module: Chart, Ward, Diagnostics