Point of care

Clinical point of care is when clinicians deliver healthcare products and services to patients at the time of care.^[1]

Clinical documentation

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.^[2] 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.^[3]

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.^[4] 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.

Electronic documentation

There are several electronic formats of documenting the clinical point of care visit. Following three technological solutions are discussed below: Electronic Medical Record (EMR), Computerized Physician Order Entries (CPOE), and Mobile EHRs (mEHR).

Electronic medical record

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.^[5] 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.^[6]

Computer physician order entries

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.^[7] Overall, such systems reduce errors due to illegible writing on paper and transcribing errors.^[8]

Mobile EMRs mHealth

Mobile devices and tablets provide accessibility to the Electronic Medical Record during the clinical point of care documentation process.^[9] Mobile technologies such as Android phones, iPhones, BlackBerrys, and tablets feature touchscreens to further support the ease of use for the physicians. Furthermore, mobile EMR applications support workflow portability needs due to which clinicians can document patient information at the patient’s bedside.^[10]

Countries

Canada

Ontario

The adoption of electronic formats of clinical point of care documentation is particularly low in Ontario. Consequently, provincial leaders such as eHealth Ontario and Ontario MD provide financial and technical assistance in supporting electronic documentation of clinical point of care through EMR.^[11] Furthermore, currently more than six million Ontarians have EMR; however, by 2012 this number is expected to increase to 10 million citizens. Conclusively, continued efforts are being made to adopt charting of patient information in electronic format to improve the quality of clinical point of care services ^[12]

References