Tips to Increase Charting at Point of Care

Our industry faces an abundance of changes. Although, one core component that remains a steady factor to achieve home care success is accurate documentation. Charting inaccuracies can be detrimental to the patient and to the provider. It’s been proven time and time again that documentation at the point of care ensures:

  • Quality patient care
  • Improved OASIS accuracy
  • Increased reimbursement
  • Enhanced patient safety

In fact, according to the article From Bedside to Billing in Home Care Technology Report, Tim Rowan, the editor, shares research on the impact of delayed documentation. The article describes a case study involving an OASIS assessment with a mock patient being completed by clinicians at the point of care in the morning, then again at noon without the patient, and then one final time at the end of the day, again without the patient present. The results show that participants’ OASIS answers are nearly 95% in agreement in the morning assessment with the patient present, less than 80% aligned with each other at noon and less than 60% in agreement at the end of the day.

It’s obvious, clinicians that choose to complete patient charting at the end of the day are much more prone to confuse patient information and forget pertinent details that could compromise patient safety. Here are some tips to help your agency implement a plan to achieve 100% documentation at the point of care:

  • Discuss with clinicians why they currently aren’t documenting at point of care. Determine the top reasons and work with the clinicians to identify ways to develop resolutions.
  • Role-play with clinicians to make them feel comfortable with documenting in front of a patient. Create a comfort zone for the clinician. This is an important strategy to achieve documentation at point of care.
  • Continue to practice with a variety of test environments and discuss and agree how best to handle documentation in each type of home setting that a clinician may encounter.
  • Create a script to explain to the patient why it is important that documentation is a part of the visit. If the benefits to the patient are clearly identified, most patients will understand that accurate documentation relates directly to their safety and care.
  • Adopt a technology solution to improve the point of care workflow process so it is easier to perform.

Are your clinicians armed with a robust technology solution that will guide them through the documentation process easily and efficiently, while in the patient’s home? Learn more about how an effective EMR solution can increase your organizations ability to document at the point of care ensuring quality care and improved patient safety.