With the advent of long term care software, Certified Nursing Assistants are now responsible for charting resident care with the help of a POC CNA charting system. This includes documenting both positive and negative changes in their condition, as well as any treatments administered.
POC CNA charting helps to create a complete picture of each resident’s health journey, which is then used to inform caregivers what treatments have already taken place and how they should proceed with future treatments.
A POC CNA charting system is a type of long term care software that nurses and physicians use to capture resident information at the point of care—when they are right next to the resident. This allows nurses to use handheld devices such as tablets to document care while the resident is seated in their room or lying on their bed.
As this documentation process is sensitive and must be precise, it would benefit CNAs and other long term care staff to apply the golden rules of documentation when documenting resident care, which are:
- If you didn’t write it down, it didn’t happen: This is the first and most important rule of documentation. When it comes to POC CNA charting, if you didn’t document it, then one can assume that care wasn’t provided. This rule is important to follow because POC CNA charting is used to create a complete picture of each resident’s health journey.
- Always add the date and time and sign each entry: Adding the date and time is important because it ensures the accuracy of all POC CNA charting entries. This is especially important when multiple staff members are documenting care for the same resident. In addition, signing each entry enables a DON (Director of Nursing) to easily track which nurse documented the resident’s care.
- Chart care as soon as it is provided: POC CNA charting should be done immediately after care is provided or shortly after. This helps to ensure that all information is accurate and up-to-date.
- Write legibly: This is no longer as much of a concern with the adoption of long term care EHRs (Electronic Health Records), as entries are typically typed into a computer. However, if a nurse is documenting by hand, it is important for the notes to be legible. This ensures that the information can be easily read and understood by others.
- Maintain accuracy: This rule goes hand-in-hand with writing legibly. All information that is documented within the POC CNA charting system needs to be accurate. This includes spelling names correctly as well as dates and times. Also, CNAs should ensure that nothing about the resident’s medical state or the care services provided is missed.
- Be systematic when charting: A nurse or physician should always chart the same way. This means having an established documentation process, with staff filling in resident information into the nursing home software sequentially. By doing so, nursing homes ensure that all important information is captured and nothing is missed.
- Maintain objectivity: All information that CNAs document should be based on facts and not on opinions. Precise medical terminology should be used to document all changes in a resident’s condition as well as any care services provided.
- If a supervising nurse is notified of a resident’s condition, include that information: If a nurse notices a change in a resident’s condition and alerts a supervising nurse, they should include the change of condition and the fact that their supervisor was notified in the POC CNA charting system. Doing so helps to ensure that during a shift change, the new nurse is made aware of the changes and can take appropriate action.
- Only use abbreviations approved for use in the facility: Although some abbreviations are commonly used in the medical field, not all of them are approved for use in all long term care facilities. Hence, a CNA should always verify with the MDS nurse what abbreviations are approved for use in the POC CNA charting system to ensure there is no confusion when reading charting entries.
- Never change what you or others have charted: Once an entry has been made into the POC CNA charting system, it cannot be altered. If a mistake was made, the CNA should consult with the administrator on what procedures the facility has in place to correct the documentation. Ideally, one should always be observant and detailed when documenting to avoid making any mistakes.
- Never chart for others or let others chart on your behalf: If another staff member charts on behalf of a CNA, or if a CNA charts for another staff member, the information in the system will be considered inaccurate, and this practice is highly unethical, as doing so could lead to medication errors that put the health and safety of residents at risk.
6 Key Attributes of a Point of Care Charting System
Having looked at what is expected of CNAs in healthcare facilities with regard to charting, we can now take a look at some key attributes that a point of care charting system must have. Each POC CNA charting system varies in features and functionalities. However, there are some key attributes that a long term care administrator should look for before they negotiate long term care software contracts.
1. Accuracy of the medical record.
All medical professionals understand the importance of accurate medical records and how they impact patient and resident health. This is especially true when choosing a POC CNA charting system. An administrator should ensure that the charting system they choose offers a wide variety of ways to increase accuracy and avoid charting errors. Efficient long term care software systems will offer the following:
- Alerts and notifications on residents’ conditions
- Built-in ADT modules to assist with admissions and discharging of residents
- An ePrescribing module for automated medication orders
- An eDocuments module for document security and easy supervision
2. Accessibility of medical records.
Another key attribute of a POC CNA charting system is accessibility. For the system to be effective, it needs to be accessible to all members of the care team. This includes doctors, nurses, CNAs, and therapists.
Some of the best LTC software providers offer mobile and desktop applications that come with cloud computing capabilities, allowing facility staff to access the system from anywhere, at any time. This is important as it allows for easy supervision of residents’ charts, remote accounting, and remote diagnosis by physicians who can quickly access residents’ records.
It is also important that the system be accessible from a variety of devices such as laptops, smartphones, and tablets. This way, no matter what type of device a care provider has, they will be able to access the system and make updates when needed.
3. Completeness and comprehensiveness of data.
The data entered into a POC CNA charting system must be complete and comprehensive for it to be useful. This means that all entries must be made in a timely manner and that all relevant information is included. Some of the best nursing home software systems offer features that help to ensure data completeness and comprehensiveness, such as:
- A built-in Kardex that displays critical information, such as the resident’s code status, preferred language, ADLs, sleep and wake times, and diet
- A work-list, enabling CNAs and administrators to quickly see what items have or have not been documented during a care session
- POC charting for MDS 3.0, ADLs, and PDPM Payment rates, which captures data and calculates the totals for most MDS 3.0 items before importing them to the long term care EHR.
- User-defined tools to meet the custom data collection requirements of each facility
4. Consistency of information.
The value of consistent information in point of care charting systems cannot be overstated. For the system to be effective, it must provide consistent information that can be relied upon by all members of the care team. When information is consistent, it is easier to track trends and make comparisons. This is helpful when making treatment decisions and for monitoring a resident’s progress.
5. Timeliness of information.
The timeliness of information is another important factor to consider when choosing a long term care software system. In order for the system to be effective, it must provide timely information that can be used by the care team to make decisions about resident care.
A POC CNA charting system should offer CNAs real-time information about their residents, with any changes to care plans or to the resident’s condition immediately updated to all relevant personnel who accesses residents’ charts.
6. Relevance of medical records.
The relevance of medical records can be defined as the ability of the system to provide accurate and up-to-date information that is relevant to the resident’s care. This means that the system must be able to track changes in the resident’s condition and update their chart accordingly.
Before an administrator enters into a new long term care software contract, they should first demo the software to ensure there are no software bugs that compromise data and that the software vendor is HIPAA compliant.
Contact us here if you would like to test drive our point of care charting software.
Point of Care Charting Benefits
We will now look at point of care charting benefits and why long term care facilities should consider adopting a POC CNA charting system. Some of the benefits of point of care (POC) charting include the following:
- Enhanced workplace efficiency: A point of care charting system can help to enhance workplace efficiency by reducing the amount of time required to complete charting tasks. This is because the system can be used to quickly and easily update resident charts as needed without having to search for paper records or input data manually. In addition, because point of care charting is carried out next to the resident, it increases efficiency, as all documentation is entered alongside the care that is administered.
- Improved resident safety: A point of care system can help to improve resident safety by providing accurate and up-to-date information that is relevant to the resident’s care. This means that the system can be used to track changes in the resident’s condition and update their chart accordingly. Also, POC CNA charting ensures that all documentation is carried out immediately, preventing inaccuracy due to negligence and forgetfulness.
- Increased accuracy: POC CNA charting systems can help to increase accuracy by reducing the amount of time required to complete charting tasks. This is because the system can be used to quickly and easily update resident charts as needed without having to search for paper records or input data manually.
- Improved regulatory compliance: A point of care system can help to improve regulatory compliance by providing accurate and up-to-date documentation relevant to the resident’s care. This means that the system can be used to track changes in the resident’s condition and update their chart accordingly.
The Importance of POC CNA Charting
POC CNA charting systems are a vital part of ensuring quality care for residents in long term care facilities. These systems can be used to quickly and easily update resident charts without having to search through paper records or manually input data. In addition, POC CNA charting systems can help to improve accuracy by reducing the amount of time required to complete charting tasks.
POC systems also improve regulatory compliance by providing accurate and up-to-date documentation relevant to the resident’s care. Ultimately, point of care charting is an important tool that can improve the quality of care for residents in long term care facilities.
CNAs using a point of care system should keep in mind the six Cs of medical records:
- Client’s words (patient or resident) should be recorded exactly as they were stated
- Clarity should be maintained by using appropriate medical terminology
- Completeness of data during charting should be observed
- Conciseness should be observed during POC CNA charting
- Chronological order of data entry should always be maintained
- Confidentiality of resident data should be observed
By following the six Cs of medical records while using an effective point of care charting software system, CNAs can rest assured that their documentation is of the highest quality, thus enabling them to provide the best possible care to their residents.
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