What Is Point of Care Documentation?

There are all kinds of senior living software on the market today, but nothing is better than point of care software for reducing errors, saving time, improving patient outcomes, and staying in compliance. With point of care software, it's easier to deliver high-quality care, save time, and ensure that patient records are secure, centralized for easy access by the medical team, and updated in real-time. 

Senior living technology solutions are designed to make caregivers' lives easier — here's what to expect when you implement PoC documentation as a part of your care delivery services. 

Point of Care Documentation for Senior Caregivers

The point of care documentation definition is self-explanatory: documentation that happens as care is delivered (the point of care). Nurses, doctors, and other healthcare professionals write down information about the patient in their chart while taking care of them.

Advantages of Senior Living-Specific Point of Care Documentation

There are many advantages to using senior living software and point of care documentation in home health or other environments. 

Point of care documentation:

• Reduces inefficiency by requiring healthcare providers to chart while working with and delivering care to seniors
• Decreases the risk of errors, as seniors and their family members are present to answer questions and clarify any misunderstandings 
• Reduces the risk of overwhelming medical providers or caregivers — hurried charting after seeing each patient (or multiple patients) may lead to errors due to rushing or being inundated with recordkeeping tasks
• Encourages information transfer, which is when information is transferred from the senior in care to the medical team and vice versa
• Helps avoid poor documentation

Point of care documentation also makes information accessible to all care team members immediately if the platform is linked to the cloud and has internet access. 

Best Practices for Implementing Point of Care Documentation in Senior Living

Point of care technology helps improve the quality of care your community members receive and encourages providers to update patient records and information as they work. It's important to use the following best practices to implement this senior living solution effectively.

Staff Training and Integration

Staff members who work directly with seniors and use point of care documentation should be trained in handling medical records and creating electronic health records through accurate documentation during an appointment. Actively taking notes during appointments or interactions with seniors is key to the PoC system.

Healthcare providers should use point of care documentation software that can be integrated into their EHR software. Using multiple programs could lead to incomplete documentation if staff keeps flipping between programs or platforms. 

Everyone working in care systems should understand that clinical documentation has the potential to prevent serious medical errors that negatively impact patient care and be trained to take notes as they work with patients to provide the highest quality of care possible. 

Security and Compliance in Documentation

Medication Administration Records (MARs) have always been an important part of healthcare. They provide a general overview of a senior's health and medical history. They also make it easier for medical teams to review patient responses, track medications, and keep accurate records. 

Paper MARs are no longer commonplace, so point of care software (such as Eldermark's Electronic Medication Administration Record (EMAR) software system) is the right choice when it comes to security and compliance. You'll remain compliant and audit-ready when the PoC documentation is accessible on a centralized platform. The best PoC software for your team should have automatic recordkeeping tools, too, so the data you need is always ready to go. 

The Eldermark all-in-one solution is also HIPAA-compliant, so you can rest easy knowing your senior communities' records are safe and secure. 

Point of Care Documentation for Resident-Centric Care

Senior living solutions like point of care documentation allow medical professionals and caregivers to create accurate, timely, and complete documentation. By taking down information during a session with a patient, it's much easier to ensure accuracy. Providers don't have to spend time completing their records later, potentially forgetting important details. 

Timely documentation is a key to resident-centric care because it helps reduce the risk of errors in their medical records. 

Here are a few point of care documentation examples showcasing its efficiency:

• Point of care documentation in home health allows nurses to take records within a senior's home rather than waiting until they return to the office. As they work with their senior client, they type out notes and complete forms on their preferred mobile devices, ensuring accuracy by allowing seniors or their loved ones to review and confirm the details. 
• Point of care documentation in a healthcare setting makes life easier for medical providers since they can input information while working with their patients. They can write down important notes within the system as they work with senior patients. Since PoC documentation is part of a larger platform of tools, they'll also have access to other information they can use to deliver quality care. 

Transform Your Point of Care Documentation Today

At the core, point of care documentation is about improving the quality of care you deliver to seniors in your community. Of course, it has other benefits, too. 

Eldermark's point of care system has enabled senior living communities to increase their capture of unscheduled services by 230%. That averages to around $25,000 in potentially missed revenue per quarter. 

And point of care systems aren't just good for saving money. They also help save time. Eldermark can help with medication management, data centralization, and more, making it faster for caregivers to get their jobs done (saving around 20 to 30 minutes per shift). 

Ready to learn more about how you can transform your services and gain the benefits of point of care documentation? Schedule your free demo now and get to know the Eldermark PoC 2 application.