From Bedside to Tech: A Nurse’s Documentation Fix

PerfectServe’s fifth annual Nurses of Note awards program honors exceptional nurses who exemplify dedication, leadership, and compassion in their work. Chosen from a large pool of nominees, these individuals regularly go above and beyond the call of duty, making a meaningful impact on patients and their communities every day. 

This year, grand prize winners were chosen in four new award categories: Innovative Technology Utilization, Excellence in Nursing Leadership, Exceptional Team Support, and Patient-Centered Care Excellence. Read the full list of winners here.

Amy Staly, BSN, RN | Innovative Technology Utilization Award 

When Amy Staly, BSN, RN, began her nursing career in her late twenties, she was driven by a clear and powerful purpose: to help people. She stepped into the fast-paced world of emergency nursing with compassion, focus, and determination. Over the next decade, Amy built a career at the bedside and rose to a leadership position as a nurse manager in a Boston-area ED. 

Amy’s journey didn’t stop there. 

Thanks to her 20 years of healthcare experience—over half of which were in health IT—she’s stepped into a new role at Clearsense, makers of a data enablement platform. 

As the Director of Clinical Product Strategy, Amy is helping to build smarter systems that empower clinicians and improve data management for health systems.

The Power of a Clinician’s Voice in Tech 

When Amy first joined Clearsense, she worked directly with clients and oversaw the clinical quality team. Now, as a leader on the technology team, she partners with developers, data engineers, and designers to ensure that the products keep clinicians top of mind.  

One of Amy’s most impactful projects—and the reason she took home the Innovative Technology Award—was her work redesigning the company’s standard clinical document tree. The tree is an essential tool for archiving legacy health records and making them accessible across EHR platforms. 

“A lot of health systems are moving to larger EMRs … and they all have these legacy systems they need to do something with. They can’t just get rid of them,” Amy said. “There’s healthcare data, there’s a retention policy that they have to follow. It’s also patient information for continuity of care. We need this as clinicians at the bedside to be able to look back, and see different records of the patient results.”  

Part of archiving existing legacy data means mapping healthcare documentation to a standard document tree. When Amy started, client document trees looked different and lacked consistency, and this made it pretty difficult for clinicians to find what they needed. Amy recognized the risk this posed to clinical workflows—and ultimately to patient safety. 

“It was deemed that it would be hard to standardize, but in healthcare, especially around electronic health records, you can standardize,” Amy said. “Technology is there to serve us, as clinicians, to help us deliver quality patient-centered care. A lot of the team members thought that, because our document trees already existed, to go back to a standard nomenclature or structure would not be possible. I believed that it was.” 

With a deep understanding of bedside care, Amy broke down the system and rebuilt it from the ground up. Along with a few other teammates, she reduced over 300 document categories to a streamlined 150, carefully organized by clinical relevance. This new structure wouldn’t just make sense to IT teams—it now makes sense to nurses, admins, and physicians alike. 

When the team rolled out the new model to their first client, Amy was excited for their feedback. But, they didn’t have any. In fact, the new document tree was accepted without a single change in just a matter of minutes—a rare and powerful endorsement of Amy’s thoughtful, user-centered design. 

“[The first client] was pleased to know [the new document tree] was based on industry standards as well as that we had worked on it internally and other clinicians had been reviewing it with me,” Amy said. “We have made it so that it’s flexible. If there is a special need, we have change management within our organization at Clearsense. We bring it forward to the right committees, the right team members to make sure that this change or this request for change is approved, that it won’t impact anything from a product standpoint.”

Innovation Rooted in Empathy 

Amy’s success in rebuilding a document tree comes down to experience and empathy. As a young nurse, she initially rejected having to shift from paper to digital documentation. She once had a circumstance where she misheard a medication order for a patient, and when she reviewed the patient’s written record, the order was different than what she’d heard and what she’d given to the patient. While everything turned out okay, she realized then that technology could prevent these miscues and help clinicians deliver better care.  

Today, she brings a unique humility and openness to her work. She understands that adopting new technology can be intimidating, and she’s made it her mission to build tools that are intuitive, accessible, and deeply supportive of the people using them. 

“This taught me that if we had better quality checks behind orders, patient safety would improve,” Amy said. “So I joined the technology bandwagon. I felt that being that voice behind helping with technology grow would be important and that I would be able to better the environment when it comes to shaping technology, which would improve policy and overall help with healthcare delivery.” 

Amy’s team embraced AI to make the document tree changes happen. Her team would meet daily to talk through what areas of the document tree could be changed. AI helped connect the dots, and the new form was born.  

The result is a scalable tool that meets the needs of busy health systems, without requiring hours of training or steep learning curves. Amy’s company does provide training as needed, but the program is designed to be very intuitive. 

“The idea was to build it in such a way that there wouldn’t need to be a lot of training on the product once it was rolled out,” Amy said. “If I’m a clinician and I go in and I have to look up a patient record and I look in our report summary for the UI, it makes sense to me. If I’m looking for an EKG, it’s going be filed under cardiology, or if I’m looking for a discharge summary from the last inpatient visit that I needed, it will be under that type of mapping.”  

Being nominated for this award made Amy feel emotional, and the moment was full circle. Even though she no longer works directly at the bedside, her career and experience have allowed her to never lose sight of the patient. 

“It hit me really hard in the heart,” she said. “Even though I’m not touching patients every day, what I do still impacts care—and to have my company and this community recognize that means the world.”

Thank You

Congratulations, Amy. Your work is a shining example of what’s possible when clinical passion meets technological vision. We’re proud to honor you as a 2025 Nurse of Note!

To learn more about Amy’s life as a nurse, we asked her a few additional questions:

If you could change one thing about the nursing field, what would it be?  

I would like to see more nurses at the decision tables. I would like to see more nurses driving policy, driving the technology and the intuition that we need behind it in order to deliver that care. Nurses are the core of patient care, so I think it’s important to have nurses at the table to drive policy and strategy. 

What advice would you give to your younger self as a nurse? 

I think it would be to remain curious. When I was in nursing, initially we documented on paper and I was an ER nurse, so you had to do it rapidly. When we were told that we were going to have to start to use a computer to document and to track patient record, I was a naysayer. I was almost kicked out of one of the classrooms. I was resisting that change because there was fear behind it. 

I would tell my younger self to remain curious, to speak up, and most importantly, never lose sight of the patient. No matter how difficult things become, if we keep the patient at the center of what we’re doing, we’ll always be headed in the right direction.

Why is nurse recognition so important?  

Nurses are at the heart of healthcare communication and collaboration, but what we do often happens quietly. We’re not the doctors who saved lives. We’re the ones who execute on the provider and physician orders. That’s why I think that it’s important to recognize nursing, because recognition fuels our resilience. It makes us feel empowered to be at the table to help make those decisions. 

What type of recognition means the most to you as a nurse?  

Being able to tell my story! When people ask me what I do for work, I tell them I am a nurse, but I work in IT. They tend to scratch their heads. So, I think having broader awards and recognition within the nursing world that doesn’t just recognize the bedside care, but also recognizes that there are nurses in other fields like IT.  

To me, this alone, just being interviewed, knowing that you’re looking at nursing outside of just the idea of healthcare delivery at the bedside and thinking about all the other careers that nursing can have within healthcare is really important.