What is point of care documentation? Point of care documentation is defined as “any documentation that is created or accessed at the point of care.” In other words, it is documentation that is created or accessed while nurses and physicians are delivering care to a patient or resident in a healthcare facility.
Thanks to the passing of the HITECH Act in 2009, point of care documentation has steadily increased, leading to the adoption of certified electronic health records (EHRs). Data collected from the Health IT between 2019 to 2021 notes that 91% of non-federal general acute care hospitals have already adopted an EHR, while 40% of rehabilitation institutions and 23% of specialty facilities also utilize an EHR.
Point of care documentation—a module usually included in a nursing home software—is essential to long term care. Facility staff that properly document point of care using their long term care software ensures that nursing home residents receive the best possible care. Good point of care documentation can also help nurses manage their time more efficiently and improve communication among staff members. This blog will discuss the importance of point of care documentation and how it benefits clinical staff and nursing home residents.
Features To Look For in a Point of Care Software
Choosing a point of care software is one of the most critical steps to creating an accurate and effective point of care documentation. When choosing a point of care software, it is essential to consider the needs of both nurses and nursing home residents. This is why nursing home administrators should consult their staff and create a list of requirements of what they expect from the software. Of course, administrators should ensure their team understands what is point of care documentation.
Examples of features to look for when choosing a point of care software include:
- Built-in Kardex: A Kardex tool/cheat sheet enables long term care staff to know their residents’ stories. A Kardex tool stores critical information like residents’ code statuses, preferred language, ADLs, sleep and wake times, diet, bathing days, and miscellaneous information. When nurses and nurse aides attend residents, they use the built-in Kardex to conveniently see the most critical information about a resident’s day-to-day needs, all on a single screen.
- Work-list: A work-list tool enables nursing staff and administrators to quickly see what items have or have not been documented during a care session or shift. The work-list gives easy-to-understand visual and text cues showing the completion of each treatment.
- User-defined tools for custom data collection: Each long term care facility has its own unique needs. Therefore, effective long term care software will include customizable user-defined tools that enable nurses and physicians to set up user-defined events complete with graphics and labels to capture items according to their facility’s requirements.
- Advanced point of care reporting: Advanced point of care reporting in a care plan software empowers nurses and physicians to deliver better care outcomes, streamlines critical processes, and yields accurate reimbursements. This means that nursing home staff have access to shift confirmations, incomplete documentation reports with visual indicators, KPI-driven dashboards, resident maintenance reports, and MDS 3.0 Item Report. All of which allows them to document any treatment that takes place accurately.
- POC charting for MDS 3.0, ADLs, and PDPM Payment Rates: The best point of care software can capture data and calculate totals for almost all MDS 3.0 items and import them to the primary long term care EHR. Using data collected at the point of care, a point of care software should be able to calculate totals for MDS 3.0 responses and export them as needed by nursing home staff.
- Pre-loaded with correlations: When choosing a point of care software, administrators should look for one that is pre-loaded with MDS 3.0 correlation items, such as ADLs (MDS 3.0 Section G – G0110 A thru J, G0120), Functional Abilities (MDS 3.0 Section GG) and Cognitive (MDS 3.0 Section C – C0700, C1000).
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Benefits of a Point of Care System
When looking at different point of care systems, it is important to identify the various features while defining what is point of care documentation and why it is important. Furthermore, it is also important to consider the different long term care software vendors who offer point of care software. Therefore, to help with the process, we have provided a helpful list of point-of-care examples in this overview of long term care vendors.
Below are some useful benefits of a point of care software system that long term care facilities will use daily:
- Reduced referrals to external healthcare providers: Point of care systems make it easier for nursing staff to document and share information with physicians. This reduces the need for referrals to specialists and other external healthcare providers.
- Faster access to treatments: Point of care systems make it easier for nurses to document and share information with physicians. This reduces the time it takes for treatments to be prescribed and initiated.
- Reduced risk of medical complications: The best point of care system has several built-in tools to alert nurses and physicians when medication is administered. It can also provide medical references for quick answers to their questions. These tools enhance point of care CNA and lead to better care outcomes. Examples of these tools include:
- ClinicalKey—a clinical search engine that nurses and physicians can search for books, medical journals, videos, and relevant clinical images.
- DynaMed—tools like the DynaMed Drug Interactions tool enable nurses to quickly and easily determine potentially harmful drug interactions.
- ACCESSSS—one-stop access to pre-appraised evidence to address this key question: what is the current best evidence available to support clinical decisions?
- Faster access to imaging services: One of the benefits of point of care systems is that they make it easier for nursing staff to document and share information with physicians. This reduces the time it takes for imaging services that are ordered and performed.
- Less paperwork: Point of care software systems are a part of creating point of care documentation. Point of care systems, therefore, make it easier for nursing staff to create electronic point of care documents while reducing the need for paper charts and paper medical records.
- Better communication: When used in tandem with other nursing home software components, a point of care system helps to minimize information transfer discrepancies between the nursing home and external providers. This prevents the incorrect transmission of medical data while enhancing the resident care process and outcomes.
What Is Point of Care Documentation, and Why Is It Important?
What is point of care documentation? It has become clear that it is care provided while beside the resident or patient. Today, this process is facilitated by way of electronic health records and long term care software systems. So why is point of care documentation important? It improves the quality of care, reducing the risk of medical errors, and providing better communication between the long term care facility and external providers. To get the most out of a point of care system, be sure to select a point of care system that has features like a built-in Kardex, work-list, advanced point of care reporting, and user-defined tools for custom data collection.