Point of Care Documentation: 7 Best Practices

Accurate documentation is vital for delivering quality patient care in the healthcare industry. Point of care documentation is a valuable tool to enhance the documentation process.

So, what exactly is point of care documentation?

Point of care documentation, or POC charting, is the recording and documenting of patient information directly at the bedside or point of care. It uses portable electronic devices instead of delayed conventional methods, such as paper-based records or desktop computer systems. It involves capturing real-time data in the electronic health record (EHR) system for patient observation, assessment, and treatment.

Why is point of care documentation important?

It is vital because it enhances accuracy and efficiency while reducing the risk of errors caused by delayed documentation. It helps you rapidly capture and update patient information to maintain comprehensive medical records. It improves access to critical patient information, facilitating better communication and decision-making among the patient’s entire healthcare team. 

What is an example of point of care documentation?

A current example of point of care documentation is using handheld electronic devices, such as tablets, to enter patient data at the bedside. Point of care solutions may also include mobile computing workstations, wall-mounted workstations, or medical carts, such as those designed by Capsa Healthcare.

Best Practices for Effective Electronic Health Record (EHR) Documentation

Adopting point of care clinical documentation improves patient outcomes and empowers patients to participate in their healthcare journey. However, to ensure an effective, safe workflow, you must address point of care documentation concerns, such as patient data security, authentication, error risk, and compliance issues, by following standard guidelines and best practices for EHR documentation.

1. Ensure Accurate and Comprehensive Data Entry in Electronic Health Records

Capturing complete patient information is crucial to ensure effective healthcare delivery. Here are some tips for accurate and comprehensive data entry:

• Verify and cross-reference patient identity and data.
• Use standardized coding systems, workflows, and templates to ensure consistency and better data analysis.
• Use real-time point of care documentation for enhanced accuracy and reduced risk of omissions or inaccuracies.
• Prioritize data completeness by including all relevant information, from past medical history, medications, and allergies to present-day vital signs and health metrics.
• Regularly review and validate patient data for consistency and accuracy.
• Use supported AIDC (automatic identification and data capture) devices to enter critical information into the EHR. An example would be using a mobile computing medication workstation with a mounted barcode scanner to automatically and accurately enter accurate data entries into the EHR.  This barcode medication administration workflow ensures the right drug was administered, to the right patient, with the right dose, at the right time, via the right route (the five “rights” of medication use).

Adhering to these practices can help you establish reliable EHRs to support informed decision-making, effective care coordination, and improved patient outcomes.

2. Maintain Timestamps and User Signatures for Document Authentication

To ensure the integrity and authenticity of EHRs, healthcare professionals must maintain timestamps and user signatures for document authentication. Timestamps record when the document is created, modified, or accessed, establishing a chronology of events. They are vital for auditing, legal purposes, and tracking changes in medical history. User or digital signatures verify the identity of the healthcare professional responsible for the documentation. They establish accountability and serve as confirmation that the data has been reviewed and approved by authorized personnel.

Timestamps and user signatures safeguard patient data against unauthorized modifications. They can help detect potential tampering and maintain the credibility and reliability of EHRs, promoting data integrity and compliance with regulatory standards.

3. Enhance Readability: Optimize Font and Text Size in EHR

Enhancing readability by optimizing font styles and text sizes in EHRs is crucial for efficient patient data retrieval. This can help reduce the risk of misinterpretation and errors. Here are some best practices for optimizing font and text size in EHRs:

• Select easily readable fonts like Arial, Calibri, or Times New Roman. Avoid decorative fonts that may hinder readability.
• Use a font size large enough for comfortable reading. A font size between 10 and 12 points for body text and a slightly larger one for headings and important information is ideal.
• Avoid light-colored text on a white background and dark-colored text on dark backgrounds. Ensure sufficient contrast between the text and background colors.
• Use consistent layouts and formatting to ensure vital information is not missed.
• Use large format displays greater than 22 inches or other EHR viewing devices that enable zooming for improved readability of text.

These tips can help you optimize font and text size in EHRs, enhance readability, improve user experience, and support data comprehension.

4. Minimize Errors and Ensure Data Integrity with Timely Documentation Entry

Delayed or incomplete documentation can affect the quality of patient care, leading to poor patient outcomes. On the other hand, timely documentation reduces the chances of errors or omissions, enabling the generation of reliable reports, analytics, and actionable insights. It allows you to capture details immediately, reducing the risk of forgetting critical information.

Timely data entry also promotes continuity of care. You can promptly record assessments, observations, and interventions so that your team has access to complete, up-to-date information. This facilitates smooth transitions in patient care, minimizes miscommunication and duplication of efforts, and improves decision-making.

You can implement technological solutions such as point of care mobile devices with alerts or reminders for prompt documentation. This can enforce real-time documentation and data authenticity and improve care coordination and patient safety.

5. Improve Patient Communication and Information Sharing via EHR

EHRs improve patient communication and information sharing in healthcare agencies. They provide immediate access to a patient’s comprehensive medical history, including diagnoses, medications, allergies, and test results. This enables informed and accurate communication with patients. Through point of care systems or patient portals, patients can access their records, care plans, and educational materials, empowering them to engage in self-care.

EHRs facilitate seamless information sharing and care coordination among teams across healthcare clinics, enabling continuity of care. Multiple healthcare providers can access and update the patient’s record in real-time, ensuring records of the most current information.

EHRs also enable the sharing of clinical guidelines, evidence-based resources, and treatment options with patients. You can discuss treatment alternatives, risks, and benefits and involve patients in shared decision-making. This promotes transparency, patient engagement, and better health outcomes.

6. Avoid Reliance on Previous Visit Notes for Current Documentation

Capturing current and up-to-date patient data is crucial for maintaining accurate medical records and delivering quality care. So, avoid relying on previous visit notes for current documentation. Previous visit notes provide valuable information about a patient’s medical history. However, they cannot serve as a substitute for current patient data.

Relying solely on previous visit notes may lead to documenting inaccurate or outdated data. Patient conditions, medications, and preferences may change over time. Failing to update records with current information can result in errors or inappropriate treatment decisions. Current documentation ensures the highest quality of care without compromising patient safety.

Additionally, healthcare providers are legally and ethically responsible for accurately documenting a patient’s visit. Previous notes may raise concerns regarding compliance during audits or legal matters.

7. Leverage Advanced Digital Health Technologies for Enhanced Patient Care

Innovative healthcare technology holds tremendous potential for enhancing patient care and revolutionizing healthcare practices. Solutions include telemedicine, remote monitoring, artificial intelligence and machine learning algorithms, digital therapeutics, wearable devices, point of care workstations, and EHRs. They enable point of care documentation in home health, fostering patient communication and engagement, remote diagnosis, and primary care delivery. These tools enhance workflow efficiency, personalize patient care, and improve patient outcomes.

Solutions To Help Deliver Quality Care to Your Patients

Implementing best practices in EHR documentation is crucial for delivering high-quality patient care. However, leveraging advanced technological solutions can help achieve this more accurately and efficiently.

Using innovative technology, Capsa Healthcare delivers flexible and reliable point of care solutions to enhance workflow efficiency and seamless communication among patients and healthcare teams. With a user-friendly interface and robust features, our solutions allow you to access and document patient information at the point of care, improving accuracy, timeliness, and overall patient care outcomes.

Contact Our Team Today