Point of Care Documentation: A Call to Action


Point of Care Documentation: Call to Action As medical professionals are trained to respond to emergency calls, the process of documenting evidence of care is becoming an essential part of the doctor-patient relationship. Often, in the face of a 911 emergency, the patient may be rushed to the hospital emergency room. A quality point of care documentation system will document the patient’s location, the time they were taken to the hospital, the medical treatment received, the staff treating them, and any other relevant information required to provide accurate, clear, and concise medical records.

Accurate & Reliable Care

In the face of increasing numbers of patients who cannot communicate their needs or speak up themselves. It is not enough for healthcare providers to rely on the physician’s notes alone. In addition, more people suffer from conditions and ailments because they are either unfamiliar or difficult to describe. The documentation of every visit becomes increasingly essential to ensure accurate and reliable care. The use of digital patient records or DORM systems has made it easier to create this documentation. The results are also precise: Patients receive better care at lower costs because their care provider can access all the necessary information quickly, easily, and confidentially.

Emotional & Mental Health

An unforeseen injury or illness can take its toll on a patient’s physical, emotional and mental health and can be devastating. But no one deserves to suffer needlessly. Doctors and other health care providers have an obligation to their patients to make sure they receive the best possible care.

Pertinent & Critical Information

In the 21st century, the rapidly evolving medical field has created a need for improved safety and accuracy in documentation practices. As a result, hospitals, clinics, home health care agencies, and nursing care facilities have also discovered the importance of maintaining accurate and reliable records. Hospitals greatly benefit from documents that contain pertinent and critical information about a patient’s health history and care. Likewise, clinics and home health agencies greatly benefit from documentation systems that enable them to rapidly and efficiently manage patient care information.

Quality Health Care

Hospitals and clinics play an essential role in providing quality health care to patients. Many people also rely on these facilities for preventive and critical maintenance, as well as emergency care. The rapid expansion of medical technology has led to the increased utilization of hospitals by both patients and providers. Both parties derive much benefit from medical record-keeping systems. Having their medical history documented and easily accessible when needed is a tremendous time and money saver for patients.

Home health agencies benefit significantly from documentation systems. These organizations provide services to their clients in need of assisted living, custodial care, or personal assistance. As medical advances continue to improve, services will expand to meet the needs of these special people. However, providing this specialized medical care is a time-consuming process with many pitfalls along the way.

Type of Documentation

Doctors rely on these records to provide accurate diagnoses and treatments for their patients. They do this by entering patient information into computerized systems. It stores and disseminates the information to other doctors and specialists in the area. It allows the doctor to offer accurate, quality care promptly. In addition, this type of documentation is particularly beneficial to new physicians entering the field. As it allows them to refer their patients to specialists for follow-up care quickly.

Final Thoughts:

Point of care documentation is a must in hospitals everywhere. Patients must have access to their copies at all times. Without it, they may be at risk of not receiving the very best care. They may also be at risk of not receiving the preventative care needed to avoid serious illness or injury later. It also helps to ensure that the best medical professionals are being utilized. For insurance companies, it helps them know that the patients they are paying are receiving the highest quality of care. For more info visit Magazines Pure


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