Point of care

Clinical point of care is the point in time when clinicians deliver healthcare products and services to patients at the time of care. Clinical point of care is the point in time when clinicians deliver healthcare products and services to patients at the time of care. Clinical documentation is a record of the critical thinking and judgment of a health care professional, facilitating consistency and effective communication among clinicians. Documentation performed at the time of clinical point of care can be conducted using paper or electronic formats. This process aims to capture medical information pertaining to patient's healthcare needs. The patient's health record is a legal document that contains details regarding patient’s care and progress. The types of information captured during the clinical point of care documentation include the actions taken by clinical staff including physicians and nurses, and the patient’s healthcare needs, goals, diagnosis and the type of care they have received from the healthcare providers. Such documentations provide evidence regarding safe, effective and ethical care and insinuates accountability for healthcare institutions and professionals. Furthermore, accurate documents provide a rigorous foundation for conducting appropriate quality of care analysis that can facilitate better health outcomes for patients. Thus, regardless of the format used to capture the clinical point of care information, these documents are imperative in providing safe healthcare. Also, it is important to note that electronic formats of clinical point of care documentation are not intended to replace existing clinical process but to enhance the current clinical point of care documentation process. One of the major responsibilities for nurses in healthcare settings is to forward information about the patient's needs and treatment to other healthcare professionals. Traditionally, this has been done verbally. However, today information technology has made its entrance into the healthcare system whereby verbal transfer of information is becoming obsolete. In the past few decades, nurses have witnessed a change toward a more independent practice with explicit knowledge of nursing care. The obligation to point of care documentation not only applies to the performed interventions, medical and nursing, but also impacts the decision making process; explaining why a specific action has been prompted by the nurse. The main benefit of point of care documentation is advancing structured communication between healthcare professionals to ensure the continuity of patient care. Without a structured care plan that is closely followed, care tends to become fragmented. Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. POC documentation is meant to assist clinicians by minimizing time spent on documentation and maximizing time for patient care. The type of medical devices used is important in ensuring that documentation can be effectively integrated into the clinical workflow of a particular clinical environment. For example, using speech recognition and information has been studied as a way to write a handover narrative and fill out a nursing handover form for clinical proofing and sign-off with promising results. Mobile technologies such as personal digital assistants (PDAs), laptop computers and tablets enable documentation at the point of care. The selection of a mobile computing platform is contingent upon the amount and complexity of data. To ensure successful implementation, it is important to examine the strengths and limitations of each device. Tablets are more functional for high volume and complex data entry, and are favoured for their screen size, and capacity to run more complex functions. PDAs are more functional for low volume and simple data entry and are preferred for their lightweight, portability and long battery life. An electronic medical record (EMR) contains patient’s current and past medical history. The types of information captured within this document include patient’s medical history, medication allergies, immunization statuses, laboratory and diagnostic test images, vital signs and patient demographics. This type of electronic documentation enables healthcare providers to use evidence-based decision support tools and share the document via the Internet. Moreover, there are two types of software included within EMR: practice management and EMR clinical software. Consequently, the EMR is able to capture both the administrative and clinical data. A computerized physician order entry allows medical practitioners to input medical instructions and treatment plans for the patients at the point of care. CPOE also enable healthcare practitioners to use decision support tools to detect medication prescription errors and override non-standard medication regimes that may cause fatalities. Furthermore, embedded algorithms may be chosen for people of certain age and weight to further support the clinical point of care interaction. Overall, such systems reduce errors due to illegible writing on paper and transcribing errors.