Point-of-care (POC) documentation has been identified as a patient safety measure for improving accuracy and timeliness of charting healthcare data.
POC Charting Systems
Clinicians enter data as they care for patients utilizing POC charting systems. These POCs are used for documentation including taking a patient’s history, detailing physical exams and assessments, and composing physician progress notes or nurses’ notes.
When first presented, POCs required substantial deviations in clinician workflow. The POCs were time-consuming and problematic to use. Bedside terminals soon began to be employed, because returning to a few terminals at the nursing station was insufficient.
Health Insurance Portability and Accountability Act/privacy concerns, and perceptions of the patients’ response to charting on computers in patient rooms were all barriers to point-of-care documentation.
Changes in both nursing practices and hospital infrastructure occurred to overcome these barriers to point-of-care documentation.
Today, POCs are more sophisticated.
Data entry is completed using wireless laptops or tablets fastened to carts. These POCs were originally referred to as computers on wheels (COWs) but are now called workstation on wheels (WOWs).
Within hospital settings, POCs centered mainly on nursing staff documentation in the past. But they are now increasingly supporting other clinicians and physicians, although to a more limited extent. Within the ambulatory setting, electronic health records (EHRs) are used by all clinicians, though particularly the physicians and nurses.
Data entered into POC systems may be structured or unstructured
- Structured or discrete data are predefined in a table or checklist for charting the patient’s information from a drop-down menu or a checklist. This enables standard values to be supplied for specific variables. The data can be applied to clinical decisions and provide standard denotation for reporting purposes.
- Unstructured or narrative data are typed or dictated reports. This is problematic to use in searches or for reporting purposes and generally are not converted into tabular or graphic form. Because the clinician is not limited to the boxes and drop-down lists, this data can be vital to guarantee comprehensive charting.
Structured data capture can transpire in a variety of ways. Very commonly, drop-down menus or checkboxes are applied to select data points on templates. Smart text is a code representing a whole phrase, sentence, or paragraph. Voice commands, touchscreen or the standard keyboard can initiate any of these methods.
A clinician may type the first few letters of the word, and “Type ahead” function can present a list of words to choose. Several EHR’s track data frequently used by the clinician and assemble a list of favorites to decrease the time it would take if selecting from a long, generic list.
Unstructured data capture transpires by the dictation processes, often using word processing functions such as copy and paste and drag-and-drop. Unstructured data entry aids can be helpful but can lead to errors and compliance issues.
The most sophisticated systems apply natural language processing to unstructured data, which permits the narrative text to be converted to structured data for processing by the computer.
Pros and Cons of POC
POC charting in patients’ rooms is a recent shift in technology use in hospitals, reducing inefficiencies, decreasing the probability of errors, promoting information transfer, and encouraging the nurse to be at the bedside.
POC charting has the potential to distract the nurse’s attention away from the patient and compromise the nurse-patient interaction.