How To Improve PoC CNA Documentation?

PoC CNA electronic documentation in healthcare is a method through doctors, nurses and CNAs document their findings from patients and evaluations. Patients’ data was recorded traditionally through paper records. However due to the inconsistent nature of information and the high amount of medical errors papers have since been replaced by more effective EHR (Electronic Health Record) software systems.

Many long-term care establishments have adopted long-term care software systems, mainly due to the fact that they have PoC documentation features which help improve charting using live data as well as being close to the resident.

One of the biggest advantages that comes from PoC CNA documentation is the higher accuracy of the entry of real-time information that improves the efficiency of workflow as well as the level of care. PoC CNA documentation eliminates the necessity care providers to “remember” specifics or make notes on paper from their interactions with residents.

Since care is documented in real-time and incorporated into a streamlined, computerized software, data integrity has significantly improved which makes the interaction between residents and caregivers more crucial. The billing department of the facility utilizes points of care systems to ensure that billing and reimbursements are accurately calculated.

PoC CNA documentation increases the efficiency and speed of accessing information about residents. The most advanced long-term care EHR programs also come with electronic Kardex features that allow caregivers can access resident data using multiple handheld devices in the building. This doesn’t just mean residents’ information is accessible to the caregivers authorized by the facility and staff, but also useful pop-up alerts for when needed.

Obstacles to using PoC Software

While it is evident that there are numerous benefits to making use of PoC software, recording points of care in addition to a resident’s information isn’t a natural thing for every person. Research has shown that there are many obstacles in PoC CNA documentation that can hinder nurses’ workflows

• Poor location for the Nursing Kiosk Computer – Facilities with larger budgets have invested in larger handheld devices, while facilities with a lower budget are limited to handheld devices and typically have stationary computers in the nursing kiosks to enter PoC information.

There are many aspects to take into consideration when choosing the computer for a nursing facility like the size of the room and access for the laptop computer the location of equipment for residents in rooms (intravenous poles as well as bedside toilets) and the restricted mobility of computers with wheels.

A stationary nursing kiosk prevents caregivers from putting in real-time data alongside the patient. Another concern is the requirement to “backtrack and recall” the exact details of care occurred and how it can influence the accuracy and reliability of the data entered by residents.

• Security of nursing Computers Like any other technology, computers in the room should monitor, test and updated to ensure that they are working properly. If the computers at the kiosks for nursing have issues with their start-up speed or the screen is frozen. These issues affect the security of the software used in nursing homes and resident information, because caregivers are less likely to utilize this software when they don’t think it will benefit their workflow.
• Privacy Concerns and HIPAA One of the main issues that caregivers face when it comes to PoC charts is the potential of disclosing sensitive data. If a nursing station is equipped with a wall-mounted computer, and the confidential information stored on handheld devices is made accessible to an unauthorised person that is an as an incidental disclosure in accordance with the HIPAA Privacy Rule.

While the risk of accidental disclosure is minimal in nature, facilities should ensure that appropriate precautions are taken to minimize the chance of a recurrence. Certain appropriate measures include safeguarding information with passwords, never leaving handheld devices in the dark and making sure that confidential information displayed on computers are seen only by authorized users.

• In-Room Computer use In-room computers can be distracting because of the alarm sounds, the tapping keys, as well as the lighting that shines from the screens of the displays, which can be disruptive to residents. These problems affect nurses’ ability to capture live-time data while sitting beside residents.
• less personal interaction – Although PoC documentation is able to boost efficiency and reduce the risk of medical mistakes, it may also detract a nurse CNA from the needs of the resident which can affect the quality of the nurse-patient interaction.
• Residents’ Perceptions of PoC CNA Charting – Studies have shown that some residents are dissatisfied with nurses if nurses chart their work electronically. Some people are dissatisfied with nurses who have their backs turned others assume nurses are using the computer to do non-work-related tasks. This could undermine trust between nurses and residents.

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5 Tips to Enhance PoC Documentation

Documenting in real-time care by using a point-of care system while in the presence of the resident has both difficulties and advantages. Naturally, there are debates about the value in PoC CNA documentation and questions regarding its capability to reduce the outcomes of patients.

An Systems 4PT study shows the need to keep in mind between the PoC documentation process in the initial assessment. The study showed that therapists who recorded between one and twenty-five percent of their points of care in addition to a patient’s information were the ones with the lowest patient progression rate. In contrast, therapists who had documented seventy-five-to-nine percent of the point of care assessment were the most advanced for outcomes of patients, resulting in lower visits.

The study also found that therapists with better training in point-of-care and stressed the use of points-of-care were more effective than those who did not record as frequently. Thus, it is crucial to keep in mind that proper point-of-care documentation is a requirement for the right training as well as discipline to be aware of the specific features of the accessibility to hardware, the documentation style and time management methods in each software system.

What are some simple methods to enhance PoC CNA documentation?

1. Get familiar with the long-term care EHR

If nurses and CNAs know how to use their long-term care EHR software and are able to use it, they are less focused on the software and concentrate on the patient. Once they have a good understanding of the long-term care program, they are able to address questions directly from residents to increase communication and make the care charting process.

2. Create a customized long-term care EHR’s functions

Modifying the long-term care EHR software lets the nurses as well as CNAs to modify the software used in nursing homes to suit their individual requirements. This helps to create a more seamless process of documentation that allows the proper data to be recorded more efficiently and accurately.

It is important to remember that when facilities decide to invest in an innovative long-term care software they must determine what their objectives are and if the software is able to accommodate them.

3. Use the services of a transcriber

If you have a complicated resident who has many symptoms and conditions It is beneficial to employ a transcriber within the facility. After the transcriber is educated to use PoC software PoC program, they are able to transcribe any recorded interactions with the resident during an evaluation visit, making it possible for the clinical staff to evaluate the resident without distraction.

It is important to note that employing a full-time transcriptionist is not always efficient in terms of cost. So, first, facilities should do a cost-benefit analysis of the payroll to determine whether it’s financially viable to use the services of a transcriber.

4. Select Compatible Devices

There is a significant connection between the point of care CNA effectiveness and usability. One of the best methods to install long-term care software is to purchase suitable devices that can satisfy the needs of the facility. If the devices aren’t easy to use or are not mobile, this can reduce the long-term care software’s capabilities and limits the staff’s movement.

Facilities must take note that all devices should be compatible with long-term care software and come with talk-to type tools or dictation software to assist in during the PoC recording process. In addition, the facility might prefer tablets or laptops instead of desktop computers, so that the personnel in the clinical department can move on the device while performing their examinations.

5. Changes in perception

Clinical staff and residents are getting more used to making use of technology in point of care assessments. If properly trained the clinical staff can utilize devices at the point of care devices without affecting the interactions of residents.

One way to do this is to notify residents prior of time of the electronic devices that will be utilized during the assessment. Another method is to sit with the resident during the test to look at the screen and go over the goals. Engaging the resident more can reduce resistance towards the device, permitting the medical staff to record information accurately.

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The importance of PoC CNA Documentation

PoC CNA documentation is crucial to improve nurses’ care in long-term care. The data collected should be clear and precise according to CMS Quality Measures detailing the types of information that are recorded, reported and designed.

Although many facilities are equipped with long-term care devices and software but these are useless without adequate training on how to use the long-term care EHR software so that appropriate PoC CNA documentation can be recorded.

Studies have revealed that poor quality documentation stems from a lack knowledge and training from nurses’ point of view. That means that there is an urgent need for more training, monitoring and continuous improvement and improved documentation procedures. These all can help to decrease the workload of nurses and help improve nursing care documentation, which ultimately improves the quality of residents’ care.