Vincentian is embarking on a new endeavor which will permit residents and family members to access Point Click Care (PCC) in real time through a smart phone, tablet or computer. What does in real time mean? It means that residents and family members will be able to read your nursing note as soon as you hit “enter”.
Why is Vincentian doing this? First of all, Vincentian values information transparency. Residents deserve to see their electronic health information as soon as it is available. Secondly, the federal 21st Century Cures Act requires Vincentian to come into compliance with its requirements which includes allowing access to certain portions of the electronic medical record.
Below is a list of the information that residents and family members will be able to view in real time. Note that clinical notes are released immediately to the resident and/or family member. The best way for staff to avoid difficult situations is to stick to the facts, observations and clinical impressions when documenting. Avoid pejorative or inflammatory statements. Document the great care you give by writing with the knowledge that the resident or family member and potentially a lawyer are going to read your note.
Allergies and Intolerances
- Medication
- Reaction
Assessment and Plan of Treatment
Care Team Members
Clinical Notes
- Consultant Note
- Discharge & Summary
- History & Physical
- Imaging Narrative Report
- Laboratory Narrative Report
- Procedure Note
- Progress Note
Health Concerns
Immunizations
Laboratory
- Tests
- Values/Results
Medications
Patient Demographics
- First & Last Name
- Suffix
- Birth Sex
- Date of Birth
- Race
- Ethnicity
- Preferred Language
- Current Address
- Former Address
- Phone Number & Type
- Email address
Problems
Procedures
Vital Signs
- Blood Pressure
- Height & Weight
- Heart & Respiratory rate
- Body Temperature
- Pulse Oximetry
- Inhaled Oxygen concentration
- BMI
Resident Goals
Smoking Status
Look for more information to come on resident access to PCC and the 21st Century Cures Act.