Streamlining systems and services not only improves the patient experience but protects medical professionals in all specialties. Clear, defined documentation provides valuable information about the patient journey to create consistency.

Point-of-care (POC) documentation was created to improve accuracy and time management. However, it’s up to the user to make the most of this tool. 

Here are seven tips for improving your point-of-care documentation.

What Is Point-of-Care Documentation?

POC documentation (or charting) is the creation of records during care delivery. In other words, a medical practitioner who documents patient care information in real-time. 

This paradigm shift in charting and documentation reflects the 2009 HITECH Act, which clarified privacy and security protection compliance around electronic data storing and sharing. The adoption of the HITECH Act made the facilitation of electronic medical or health records (EMR or EHR) possible. 

Access to EHR ensures accurate, up-to-date medical access between facilities and specialties. Hospitalists can capture point-of-care documentation with a hospitalist app to share with care teams across facilities and specialties with the click of a button.

Point-of-care documentation refers to the practice of recording patient information, clinical observations, and other relevant data directly at the location where patient care is being provided. This approach is commonly used in healthcare settings, such as hospitals, clinics, and doctor’s offices, where healthcare professionals document information in real-time while interacting with patients.

Point-of-care documentation offers several advantages, including:

  1. Accuracy and Timeliness: Healthcare providers can record accurate and up-to-date information about the patient’s condition, treatment, and progress immediately after assessing them. This helps prevent errors and ensures that the most current information is available for decision-making.

  2. Enhanced Communication: Point-of-care documentation facilitates better communication among healthcare team members. All team members have access to the most recent information, allowing for more coordinated and effective care.

  3. Efficiency: Documenting information at the point of care reduces the need to remember details and enter them later in a different location. This streamlines workflows and saves time for healthcare professionals.

  4. Patient Engagement: Involving patients in the documentation process at the point of care can help them understand their conditions, treatment plans, and progress. This engagement can lead to better patient satisfaction and adherence to treatment.

  5. Clinical Decision-Making: Immediate documentation allows healthcare providers to make informed decisions based on the most recent data. This is crucial for adjusting treatment plans, medications, and interventions in real-time.

  6. Legal and Regulatory Compliance: Accurate and timely documentation is essential for meeting legal and regulatory requirements in healthcare. Point-of-care documentation helps ensure that all necessary information is captured and documented appropriately.

  7. Reduced Duplication: Documenting information directly at the point of care minimizes the need for duplicate entries or redundant documentation, reducing the risk of errors and inconsistencies.

Healthcare professionals often use electronic health record (EHR) systems or mobile devices to document patient information at the point of care. These systems enable secure and efficient documentation, while also ensuring that the information is accessible to authorized personnel across various healthcare settings.

It’s worth noting that while point-of-care documentation offers many benefits, it also requires proper training and adherence to privacy and security protocols to protect patient confidentiality and sensitive information.

Why Point-of-Care Documentation Matters

POC documentation ensures consistent patient care between medical providers. Every time a different medical professional comes in contact with a patient, it creates the potential for gaps in care. Whether it’s an ER doctor creating notes for a referring physician or a psychiatry consultant noting their findings, these records help prevent errors in medical care. 

Preventing medical errors is integral for prioritizing the health and wellness of the patient, but it also protects the practitioner’s career. 

Should an issue arise, well-documented visits could be what saves a physician from a malpractice suit— whether it’s founded or not. It’s essential to understand that if something isn’t documented, it didn’t happen in the eyes of the law. 

For example, say a patient discloses that they haven’t been taking their medication, and it leads to preventable side effects. In this case, the physician could be found liable if they don’t note the patient’s disclosure.

POC documentation is also critical for streamlined billing and centralization. Consultants require accurate charting and coding to receive proper payment from hospitals and medical facilities.

Capturing patient progress notes at the point of care improves accuracy and timeliness in the charting process. With these considerations in mind, here are seven tips for improving POC documentation.

1. Invest in the Right Tools

Choosing the right tools for POC documentation is foundational for success. Look for something that offers centralization in the documentation and medical billing with full mobile functionality. Using a smart system with progress note generation and automation can also help simplify the note-taking process.

Selecting a system with EHR access and compatibility is paramount for consultants traveling between facilities. Autocorrect and speech-to-text can also assist with the time management side of POC charting.

2. Create Time Management Systems

While the tools you use will play a pivotal role in your time management success, building systems and habits is also crucial.

Create habits that integrate into your workflow and schedule to ensure you’re making time to capture POC notes. Set aside a few minutes at the start and end of every session for charting. Capitalize on downtime to review notes and elaborate or clarify as needed.

3. Prioritize Accuracy

Accuracy is everything when creating POC documentation. Failure to include accurate details or descriptions could lead to malpractice suits and billing disputes. 

Consider the seven Cs of communication:

  • Clear – another practitioner reading your notes with no other context should be able to understand and act accordingly.
  • Correct – everything in your documentation should be triple-checked for accuracy.
  • Complete – provide a complete picture of the patient’s journey and care so far.
  • Concrete – avoid using subjective or unsure phrases like “I think” or “I believe.” Everything should have evidence and reasoning. 
  • Concise – avoid frilly language and elaborate descriptions. Take the less is more approach and use bullet points as appropriate.
  • Considered – think before you note and consider your words before saving.
  • Courteous – don’t let personal opinions about the patient or family cloud your documentation; the presence of emotive thinking could damage your integrity in a lawsuit.

Scanning through your charts through the lens of the seven Cs of communication will help you create detailed, understandable documents.

4. Manage Expectations With Patients

Technology is now commonplace in medical appointments. Patients are becoming more accustomed to computers and tablets being present during consultations. However, it’s courteous to manage expectations and let your patient know that you’ll be taking notes using your device before you get started.

Managing expectations with patients is a crucial aspect of providing effective healthcare and ensuring patient satisfaction. It involves setting clear and realistic expectations about various aspects of their care, treatment, and overall experience. Here are some key strategies for managing expectations with patients:

  1. Clear Communication: Open and honest communication is essential. Clearly explain the diagnosis, treatment options, and potential outcomes in a way that the patient can understand. Use simple language and avoid medical jargon.

  2. Listen Actively: Take the time to listen to the patient’s concerns, questions, and preferences. Address their individual needs and involve them in the decision-making process.

  3. Explain Procedures and Processes: If a procedure or treatment is planned, provide a step-by-step explanation of what to expect before, during, and after. This can help alleviate anxiety and uncertainty.

  4. Realistic Expectations: Set realistic expectations regarding the outcomes of treatments or interventions. Be honest about the potential risks, benefits, and limitations.

  5. Timeframes: Provide an estimate of how long it might take to see improvements or results. This helps patients understand that progress may take time and prevents unrealistic expectations for immediate changes.

  6. Possible Complications: While focusing on positive outcomes, also discuss potential complications or setbacks that could arise. This prepares patients for any unexpected challenges.

  7. Informed Consent: Obtain informed consent before any procedure or treatment. This involves explaining the procedure, risks, benefits, alternatives, and allowing the patient to ask questions before giving their consent.

  8. Availability and Communication: Let patients know how they can reach you or your healthcare team if they have questions or concerns. Respond promptly to messages and calls.

  9. Collaborative Decision-Making: Involve patients in decisions about their care. Discuss treatment options, and consider their preferences and values when determining the best approach.

  10. Follow-Up Plans: Clearly outline follow-up plans, including appointments, tests, and any necessary lifestyle changes. This helps patients understand the ongoing nature of their care.

  11. Respect Cultural Differences: Consider the patient’s cultural background and values when discussing treatment options and care plans.

  12. Address Financial Concerns: Discuss potential costs and insurance coverage, if applicable. Being transparent about financial aspects helps avoid surprises and financial stress.

  13. Patient Education Materials: Provide written or digital materials that summarize important information, treatment plans, and instructions. This allows patients to refer back to the information at their convenience.

  14. Continuous Updates: Keep patients informed about any changes in the treatment plan, new information, or unexpected developments.

Remember that managing expectations is an ongoing process that requires empathy, active listening, and adapting your approach based on individual patient needs. By fostering open communication and building trust, you can help patients feel more informed and empowered throughout their healthcare journey.

5. Maintain a Human Connection

One of the challenges with EHR and charting apps is the intrusive nature of technology. While patients expect you to take digital notes, it shouldn’t be the entire focus of your appointment. 

Maintain a human connection by making eye contact, setting the tablet or laptop to the side (not between you and the patient), and taking notes in bursts.

6. Self-audit Your Charts

Set some time aside at the end of the day to look over your charting and confirm that it’s detailed and accurate. It’s also worth revisiting your notes every quarter to identify behavioral trends and opportunities for improvement.

7. Record Amendments

It’s not reasonable to expect 100% accuracy during the first pass with documentation; many medical professionals review their charts and identify areas where more context or accuracy is needed.

If you determine adding or adjusting something in your charts after the fact is necessary, make detailed amendments; don’t delete previous entries. Add your changes with a date, initial, and reason for the amendment. 

Deleting information can look like you’re trying to hide a mistake if someone reviews your notes. This is particularly suspicious as the world goes digital, as electronic records have metadata. Nothing is truly deleted in the digital age; an attorney can easily get a subpoena for your metadata and see what you deleted and when.

Final Thoughts

POC documentation is becoming more commonplace in hospitals, community health clinics, and private practices. Investing in the right solutions and honing your charting habits will help protect your integrity and resources as a medical professional.

Categories: Health

Nicolas Desjardins

Hello everyone, I am the main writer for SIND Canada. I've been writing articles for more than 12 years and I like sharing my knowledge. I'm currently writing for many websites and newspapers. I always keep myself very informed to give you the best information. All my years as a computer scientist made me become an incredible researcher. You can contact me on our forum or by email at [email protected].