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PoC CNA electronic documentation in healthcare is a way by which nurses, physicians, and CNAs record their patient findings and assessments. Patient data was traditionally recorded via paper documentation. However, due to the inconsistency of data and a high number of medical errors, paper documentation has since been replaced with more efficient EHR (Electronic Health Records) software systems. 

Many long term care facilities have adopted long term care software systems in large part because they include PoC documentation functions that improve charting with real-time data while being beside the resident. 

One of the most significant benefits of PoC CNA documentation is the increased accuracy of entering real-time data, which improves workflow and the quality of care. PoC CNA documentation eliminates the need for caregivers to “remember” details or write notes by hand from their interactions with residents. 

As care is now documented in real-time and entered into an intuitive, computerized system, data integrity has been dramatically improved, making the interactions between caregivers and residents even more important. The facility’s billing team also use point of care systems to ensure billing and reimbursements are calculated accurately.   

PoC CNA documentation increases the speed and convenience of accessing resident information. State-of-the-art long term care EHR software systems also have electronic Kardex functions so caregivers can view resident data from multiple handheld devices anywhere within the building. This not only means resident information is readily available to authorized caregivers, but they also have handy pop-up warning alerts when necessary.

Barriers to Using PoC Software

While it is undeniable there are many benefits of using PoC software, documenting point of care besides a resident does not come naturally to everyone. Studies show that there are several barriers to PoC CNA documentation that can impact nurses’ workflow:

  • Poor Location of the Nursing Kiosk Computer – Bigger facilities have invested in more handheld devices, while facilities with a smaller budget have limited handheld devices and typically use stationary computers by the nursing kiosk to enter PoC data. 

There are several factors to consider when using a nursing kiosk computer, such as the room size and access to the computer, placement of resident equipment in the room (intravenous poles and bedside commodes), and the limited maneuverability of computers on wheels. 

Nurse entering her PoC CNA electronic documentation to record patient findings and assessments.
PoC CNA is electronic documentation used by nurses, physicians, and CNAs to record patient findings and assessments.

A stationary nursing kiosk restricts caregivers from entering real-time information beside the resident. Another potential issue is the need to “backtrack and remember” what care has taken place, all of which can impact the reliability and accuracy of entering residents’ data. 

  • Reliability of Nursing Computers – As with any technology, in-room computers will need to be monitored, tested, and upgraded to ensure they are in full working order. Suppose the nursing kiosk computers have slow start-up issues or the screen freezes. Such matters impact the reliability of the nursing home software and the resident data, as caregivers are less inclined to use the software if they do not believe it is beneficial to their workflows. 
  • HIPAA/Privacy Concerns – One of the biggest concerns caregivers have when entering PoC charting is the possibility of disclosing sensitive information. If a nursing kiosk has a wall-mounted computer and confidential information on a handheld device is made visible to an unauthorized person, this counts incidental disclosure according to the HIPAA Privacy Rule

While incidental disclosure is limited in nature, facilities must ensure reasonable measures are in place to lessen the likelihood of an occurrence. Some appropriate measures include protecting data with passwords, not leaving handheld devices unattended, and ensuring confidential data on computer screens are seen only by authorized personnel. 

  • In-Room Computer Use – In-room computer use can be distracting with the alert noises, tapping keys, and the light shining from the display screens, disturbing residents. These issues impact the nurses’ willingness to record real-time data while beside a resident.
  • Less Personal Interaction – While PoC documentation has the potential to improve efficiencies and reduce medical errors, it can also distract a nurse or CNA from the resident’s needs, harming the nature of nurse-patient interactions. 
  • Resident Perceptions About PoC CNA Charting – Studies show that some residents become dissatisfied with nurses when they chart electronically. Some are unhappy when nurses have their backs turned, while at other times, they mistakenly think that nurses are using the computer for non-work-related activities. This can diminish trust between residents and nurses. 

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5 Ways to Improve PoC Documentation 

Documenting real-time care using a point of care system while beside a resident comes with both challenges and benefits. Naturally, there are discussions about the efficacy of PoC CNA documentation and questions about its ability to lower patient outcomes. 

A Systems 4PT study demonstrates the need to balance the PoC documentation process during the initial evaluation. The study revealed that therapists who documented one to twenty-five percent of their point of care besides a patient had the lowest patient progression rate. Meanwhile, therapists who documented seventy-five to ninety-nine percent during their point of care evaluation had the highest progression rate for patient outcomes resulting in fewer visits. 

The study also recognized that therapists who had better point-of-care training and emphasized using point-of-care were more successful than therapists who did not document as often. Therefore, it is essential to remember that adequate point-of-care documentation requires training and discipline to understand the unique functions behind the hardware accessibility, documentation style, and time management techniques for each software system.

So what are some easy ways to improve PoC CNA documentation

Nurse familiarizing herself with PoC software to improve the accuracy of point of care documentation.
PoC software helps to record point of care documentation while beside a resident.
  1. Familiarize yourself with the long term care EHR

When nurses and CNAs understand how to use their long term care EHR software system, they intuitively spend less time concentrating on the system and instead focus more on the resident. Once they are familiarized with the long term care software, they can ask residents questions more directly to improve communication and streamline the point of care charting process better. 

  1. Customize the long term care EHR’s functions

Customizing the long term care EHR software system allows nurses and CNAs to tailor the nursing home software to meet their specific needs. In turn, this allows for a smoother documentation process that enables the correct data to be collected more accurately and efficiently.

It is worth noting that when facilities invest in a new long term care software system, they need to determine what their goals are and whether the software can accommodate these goals. 

  1. Employ a transcriber

When there is a particularly complex resident with multiple symptoms and ailments, it is helpful to have a transcriber employed in the facility. Once the transcriber is trained on using the PoC software, they can transcribe any recorded resident interactions during an evaluation visit, thus allowing the clinical staff to assess the resident distraction-free.  

It is also worth mentioning that employing a full-time transcriber may not be very cost-effective. Therefore, facilities should first conduct a cost-benefit analysis on payroll to see if it is financially viable to employ a transcriber. 

  1. Choose Compatible Devices

There is an important connection between point of care CNA efficiency and its usability. One of the best ways to implement long term care software is to invest in compatible devices that meet the facility’s needs. If the devices are difficult to type on or are stationary, this reduces the long term care software capabilities while restricting staffs’ movement. 

Facilities should be mindful that devices need to be compatible with the long term care software and have talk-to-type features or dictation tools to aid the PoC charting process. Alternatively, the facility may want to provide laptops or tablets rather than desktop computers so the clinical staff can move around with the devices while conducting their assessments. 

  1. Changing perceptions

Residents and clinical staff alike are becoming more accustomed to incorporating technology during the point of care evaluations. With adequate training, clinical staff can use point of care devices without impacting resident interactions. 

An easy approach is to inform residents ahead of an appointment that an electronic device will be used during an assessment. Another approach is to sit beside the resident while conducting the assessment to see the screen and review goals. Engaging with the resident better will reduce any resistance to the device, thus allowing clinical staff to document data accurately. 

The Importance of PoC CNA Documentation

Nurse conducting PoC documentation with a patient during the initial evaluation.
The PoC documentation process during the initial evaluation is essential for better patient outcomes.

PoC CNA documentation is crucial for improving the quality of nursing care in long term care. The data collected must be transparent and accurate in line with CMS’ Quality Measures stipulating what data is collected, reported, and developed.  

While many facilities have integrated long term care software and compatible devices, these are rendered useless without sufficient training in using the long term care EHR software functions so that proper PoC CNA documentation can be collected.

Past studies have shown that the poor documentation quality derives from a lack of training and understanding from the nurses’ perspective. This means there is a major need for more training, continuous monitoring, and better documentation processes. All of these can serve to reduce nurses’ workload and improve nursing care documentation to ultimately increase the quality of resident care.  

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Cindy Wong
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