NewsLine — September 2009 - (Page 15)

Point-of-Care Documentation: Perception Versus Reality By Jill Cornwell, RN T he perception of staff regarding their transition to point-of-care (POC) documentation has proven to be one of the greatest challenges to adopting this new model in hospice and palliative care. Many staff, including nurses, social workers and chaplains, have voiced their concerns that taking a laptop or tablet to the bedside of a dying patient will create a barrier to care. This perception may be based on the fact that they do not feel comfortable with their own ability to use the technology and are perfectly comfortable with the old process about which they have knowledge and understanding. When we don’t understand something, we inherently reach back to what makes us feel comfortable. The role of hospice and palliative care leadership is to provide staff with the knowledge and understanding of how POC documentation can improve the delivery of care. The most important thing to stress is that such documentation is only as good as the staff members who complete it in a timely fashion so as to make it available to everyone else. Traditionally, nurses and other members of the interdisciplinary team have visited patients in their homes and have done minimal documentation at the bedside. They then go back to an office, the car, or home to complete their paperwork. Because staff members have become so comfortable with this, they have forgotten that when they worked in the acute care environment, such as a hospital, they were required to complete documentation by the end of each shift. Stress to your staff that the sooner the documentation is recorded, the more accurate it will be. When I was a child, I remember a game we played where someone showed us several different items in a box. We were allowed to look at the items for a few minutes and then the box was closed. The object of the game was to see how many items you could remember after several minutes. Usually you would remember some items quickly but after a short time, fewer would come to mind. This is also true in your observation of patients. The color of the skin, the respiratory pattern, facial grimacing and wound appearance are examples of things that are more accurately recorded as soon as they are observed. Excellent Tool for Monitoring the Plan of Care POC documentation can be an excellent tool for tracking the history of a patient’s symptoms and improvement or decline in condition. Software programs should offer the ability to easily refer back to previous notes or assessments. An example would be the ability to look back at the last few pain assessments to see how the plan of care is working to improve symptoms. Another would be the ability for an on-call nurse to see when a catheter was changed, or what type of wound care is being used for a particular site. The availability of this information saves time and phone calls as well as trips to the office to look at a paper chart. The ultimate advantage becomes improved continuity of care and care delivery. POC documentation also assists nurses with updating medication profi les and reconciliation of medications at the bedside. Electronic documentation programs can When we donÍ t understand something, we inherently reach back to what makes us feel comfortable. continued on next page NewsLine 15

Table of Contents for the Digital Edition of NewsLine — September 2009

NewsLine - September 2009
Contents
Introduction
Archstone Foundation Grant: Exploring the Role of Spiritual Care in Palliative Care
Working for a Greener Future
Transforming Care at the Bedside
Point of Care Documentation: Perception Versus Reality
A Technophobe Signs On
Utilizing Volunteers More Fully
HIPAA and Technology: Some Considerations
Keeping the Attending Physician Involved

NewsLine — September 2009

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