PointClickCare®’s Point of Care (POC) Experience: If It Isn’t Documented, It Didn’t Happen

To some in the skilled nursing facility (SNF) arena, documentation can seem unnecessary and overly time consuming. However, when documentation isn’t completed, there is no proof that what happened, happened.  In SNF settings, documenting resident care is required from not only the licensed staff, but also nurse assistants.

Fortunately, how we capture that documentation has evolved over the last decade from paper to computer-based programs. These programs allow point and click or touchscreen functionality, including the completion of activities of daily living (ADLs). They also enable staff to not only identify what is required for a specific individual while providing direct care (i.e., care plan/kardex/specific instructions), but also to easily capture the activities/tasks completed. In turn, this provides greater accuracy. 

This wonderful innovation of being able to link information from one area to another electronically has decreased errors, saved valuable labor hours and enhanced documentation.  Point of Care (POC) is an area that has built-in links providing numerous benefits. It is often overlooked for the value that it has.  Not only does it capture ADLs, but it also aids nursing in capturing additional data by more easily tracking and reporting it. POC links various areas that capture the necessary supportive documentation, restorative care, ADLs, MDS, behaviors, weights and vitals. Weights and vitals are also linked back to the resident record and into the resident header for easy viewing. POC completion is easily tracked at any given time, down to the specific task via the Clinical Dashboard and report options.

Related Blog: How it Works: Medicare Level of Care (LOC) in PointClickCare^® For the Management of No Pay and Exhaust Bills

There are endless ways you can track what’s going on with your residents. In addition to reports, you can set up alerts that indicate what residents are at risk, even if the nurse aide forgets to let you know someone had a behavior or change in condition. POC provides tools and reports that you need now more than ever to avoid possible transfers to the hospital, not to mention the well-being of your residents.

There are also great opportunities for your leadership or management team to benefit from the electronic evolution. Enhanced monitoring features such as dashboards, integrated documentation look-back and reports are extremely useful. Required chart review or review of hard copy documentation, which was often incomplete, is now available at a moment’s notice and can be available for supportive quality assurance documentation. 

Next time you consider staying on paper flowsheets or another system that isn’t integrated with PointClickCare^® (PCC), stop and think about all of the valuable time-saving features you will be missing out on, as well as the risk you face each time you encounter missing documentation.  POC can help you capture more than just bathing. It can help you avoid the issues that can occur if it isn’t documented—because if it isn’t documented, it didn’t happen.