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.

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.

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.