Point Click Care Charting: A Deep Dive Into The Hidden Details (A Beginner-Friendly Guide)

Point Click Care (PCC) is a widely used Electronic Health Record (EHR) system in the long-term care industry. While the basics of charting in PCC are often covered in initial training, mastering the system requires understanding its nuances and hidden details. This guide aims to provide you with a step-by-step approach to enhance your PCC charting skills, ensuring accuracy, efficiency, and compliance.

Prerequisites:

  • Basic Computer Literacy: Familiarity with navigating a computer, using a mouse, and typing.

  • PCC User Account: A valid PCC user account with appropriate permissions granted by your facility administrator.

  • Understanding of Care Plan Goals: A solid grasp of the resident's care plan goals and interventions is crucial for accurate and meaningful charting.

  • Familiarity with Facility Policies: Adherence to your facility's specific policies and procedures regarding documentation is essential.

    • Tools Required:

  • Computer with Internet Access: A reliable computer with a stable internet connection is necessary to access PCC.

  • PCC Login Credentials: Your username and password for accessing the PCC system.

  • Resident Chart: Access to the specific resident's chart you are documenting for.

  • Facility Policy Manual: A readily available copy of your facility's policy manual for reference.

  • Care Plan: A printed or electronic copy of the resident's current care plan.

    • Step-by-Step Guide:

    1. Accessing Point Click Care:

    * Open your web browser: Launch your preferred web browser (e.g., Chrome, Firefox, Edge). Ensure it's a supported browser for PCC. Check with your IT department if unsure.
    * Enter the PCC URL: Type your facility's specific PCC URL into the address bar and press Enter. This URL is usually provided by your facility administrator.
    * Login: Enter your username and password in the designated fields. Double-check for typos. If you have forgotten your password, use the "Forgot Password" link or contact your IT department.
    * Select the Resident: Once logged in, you will likely be presented with a list of residents. Locate and select the resident you need to chart on. You can use the search function to quickly find the resident by name or room number.

    2. Navigating the Resident Chart:

    * Understand the Sections: Familiarize yourself with the different sections of the resident's chart. Common sections include:
    * Face Sheet/Demographics: Basic resident information.
    * Care Plan: The resident's individualized care plan.
    * Assessments: Initial and ongoing assessments (e.g., Minimum Data Set - MDS).
    * Daily Notes/Progress Notes: Where you'll document daily observations and interventions.
    * Medication Administration Record (MAR): Records medication administration.
    * Treatment Administration Record (TAR): Records treatments performed.
    * Physician Orders: Physician's orders for the resident.
    * Use the Navigation Menu: Utilize the navigation menu (usually on the left side of the screen) to quickly jump between different sections of the chart.

    3. Creating a Daily Note (Progress Note):

    * Locate the Daily Notes Section: Navigate to the "Daily Notes" or "Progress Notes" section of the resident's chart.
    * Create a New Note: Click on the "New Note" or similar button to create a new entry.
    * Select the Appropriate Note Type: PCC often allows you to select a specific note type (e.g., Nursing Note, CNA Note, Social Services Note). Choose the note type that best reflects your role and the information you are documenting.
    * Enter the Date and Time: Ensure the date and time are accurate. PCC typically automatically populates this information, but double-check it.
    * Begin Documenting: Start writing your note. Be specific, objective, and concise. Use measurable terms whenever possible. Avoid vague language like "resident seems happy." Instead, document "resident smiled and stated, 'I am feeling good today.'"
    * Address Care Plan Goals: Directly relate your documentation to the resident's care plan goals and interventions. For example, if the care plan goal is "Maintain skin integrity," your note should document your observations of the resident's skin and any interventions performed (e.g., application of barrier cream).
    * Document Interventions: Clearly document all interventions you performed for the resident, including the time, method, and resident's response.
    * Document Observations: Record any significant observations about the resident's physical, cognitive, or emotional status.
    * Use Drop-Down Menus and Templates: Utilize the drop-down menus and pre-defined templates provided by PCC to streamline your documentation. However, always customize the information to reflect the specific resident and situation.
    * Avoid Copying and Pasting: While templates are helpful, avoid simply copying and pasting information from previous notes. This can lead to inaccurate documentation and legal issues. Each note should be an accurate reflection of the current situation.
    * Save the Note: Once you have completed your documentation, click the "Save" or "Submit" button to save the note.

    4. Utilizing PCC's Advanced Features:

    * Keyword Search: Use the keyword search function to quickly locate specific information within the resident's chart. This can be helpful for reviewing previous documentation or identifying trends.
    * Customizable Templates: Explore the option of creating customized templates for frequently documented situations. Consult with your supervisor or IT department for assistance with creating and implementing custom templates.
    * Task Management: Use PCC's task management features to assign and track tasks related to resident care.
    * Reporting: Familiarize yourself with the reporting capabilities of PCC. You can generate reports on various aspects of resident care, such as medication administration, skin integrity, and falls.

    Troubleshooting Tips:

  • Slow Performance: If PCC is running slowly, try clearing your browser's cache and cookies.

  • Login Issues: Double-check your username and password. If you are still unable to log in, contact your IT department.

  • Error Messages: Pay attention to any error messages that appear. They often provide clues about the problem. If you are unsure how to resolve the error, contact your IT department or supervisor.

  • Lost Data: Save your work frequently to avoid losing data in case of a system crash or power outage.

  • Missing Information: If you cannot find the information you need in the resident's chart, contact the appropriate staff member (e.g., nurse, therapist).

Summary:

Mastering Point Click Care charting involves understanding its features and utilizing them effectively. This guide provided a step-by-step approach to navigating the PCC system, creating accurate and meaningful daily notes, and leveraging advanced features. Remember to prioritize accuracy, objectivity, and compliance with facility policies. By consistently applying these principles, you can become a proficient PCC user and contribute to providing high-quality care for your residents. Continuous learning and seeking assistance when needed are key to maximizing your PCC charting skills.