Portable documentation comes to resident care: what "point-of-care" information technology means to caregiving operations.

Whenever and wherever nurses make decisions that affect patient care, whether at the bedside or in the nursing administration office, they must have easy, quick access to information that affects the quality of their decisions." (1) The authors of "Integrating systems for better patient care" wrote that statement 12 years ago. They also stated that nursing information systems have made communication and documentation easier and faster for nurses, and that the appropriate use of integrated systems technology will enable nurses to increase their accountability and gain the knowledge and information they need to deliver effective care at the lowest cost.

And yet although some industry pioneers saw the importance of information access 12 years ago, healthcare is just now implementing advances toward technology that provides more immediate access to critical information. Especially considering the number of regulations that encompass long-term care, it has become increasingly important to document everything and ensure staff take proper steps to do so.

How do you do that? By integrating point-of-care systems into the healthcare process, which ensures accurate billing, better reimbursements, more efficient staffing and, ultimately, better resident care.

Mobile Clinical Charting Technology

Several long-term care technology providers are starting to support small, portable devices and/or kiosks that can be located throughout a facility to give nursing staff the easy, quick access to information they need. These devices allow nursing staff to care for residents while documenting vitals and entering real-time information. This enables nurses to promote timely communication among nursing staff, physicians, pharmacies, etc. In the end, quality of care improves and potentially negative resident outcomes decrease.

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Without simplified, mobile clinical charting systems, when a patient registers a fever, for example, the nursing assistant marks it on the patient's assignment sheet and returns to a station to enter data in the vitals book. The attending nurse enters data into the patient's chart and may notice that the abnormal change requires additional care. The nurse pages the doctor, who then calls back to the nursing station, hoping that the nurse who found the abnormality is still on duty so that he/she can call in a preliminary diagnosis and order lab/radiology tests and medication. The nurse completes the telephone order process and calls the pharmacy, lab, and/or radiology. The provider then delivers the medication and/or takes the specimen/x-ray. Once test results are available, the provider notifies the facility and, in return, the facility must contact the physician again. The tremendous amount of administrative time and work involved in all this complicates and delays the delivery of real hands-on care to the patient.

A point-of-care system, as both a communication device and a data-recording device, gives nurses more productive time with residents. They don't have to keep running back to binders or search for the resident's chart at the station to look up care needs and record care provided, vitals, intake/output, and so forth.

In addition, staff are not waiting until the end of a shift to remember and record what 30 residents ate for breakfast and lunch, nor are they waiting for someone else to finish using the binder so that they can complete their MDS supporting documentation. Portable devices allow more than one person to access resident records, instead of one person monopolizing the paper record.

Inaccurate or absent resident care documentation:

* inhibits the ability to meet care needs, such as providing safe, quality care supported by a care plan;

* leads to lower RUG scores and reimbursements;

* contributes to potential loss of reimbursement if the facility is unable to produce supporting documentation for chart audits;

* could produce survey deficiencies if supporting documentation is unavailable for chart audits or if an accurate record of resident care needs and care provided is unavailable; and

* poses the potential for litigation without proper documentation of chart audits and resident care needs versus resident care provided.

Precautions 

Transitioning to point-of-care technology requires a comprehensive review of the facility's culture, a complete needs assessment, and an informed vendor selection process. Knowing what a system can provide and how it can simplify processes requires thorough research, keeping in mind that automation does not solve every problem.

With the right change-management process, facilities can generate excitement around such a valuable tool. To create enthusiasm and keep staff involved, facilities should follow a few important steps:

* Review facility standards and practices.

* Update policies, procedures, and assessments to align them with corporate and CMS requirements.

* Develop a migration, or adaptation, path--essential to staff buy-in.

* Include both upper management and an interdisciplinary team in the implementation process.

* Build trust and reduce anxiety by educating all stakeholders.

* Identify realistic time frames and milestones that staff can celebrate as they are achieved.

Also, to ensure that the transition to electronic documentation is virtually seamless, look for a vendor with a proven methodology for effectively and efficiently implementing and training a client in this technology, as well as one that can support the facility in whatever way necessary to achieve success. And choose a point-of-care system that integrates with your clinical and financial software through real-time exchange of data to ensure information perfectly transfers from one technology to another. Simply sharing records automatically, downloading data, or running reports to gather information only to reenter it into another system defeats the purpose of point-of-care technology and imposes the risk of data entry errors.

Technologies such as this can have a very positive impact on the industry because they promote more accurate, timely care and documentation to support reimbursement. They empower the frontline staff by reinforcing the message that the care they provide is so vital to the organization that the corporation and stakeholders are willing to invest in their adaptation.

Beth DeLaHunt, RN, BAN, had 25 years' experience in the long-term care industry, including ten years as a DON, prior to joining Achieve Healthcare Technologies, where she is the company's clinical expert for its newest Web-based product, Achieve Matrix. For further information, phone [phone], ext. 9791, or visit www.achievehealthcare.com. To send your comments to the author and editors, e-mail [e-mail]. To order reprints in quantities of 100 or more, call [phone].

Reference

1. Nursing informatics: Enhancing patient care. Priority Expert Panel Report, vol. 4. NIH Publication No. 93-2419. Bethesda, Md.: National Institute of Nursing Research; National Nursing Research Agenda; May 1993. Available at: http://ninr.nih.gov/ninr/research/vol4/index.html.

BY BETH DELAHUNT, RN, BAN