PCC Presentation_18JUN2025.pptx

Welcome to PointClickCare Training

• PointClickCare (PCC) is a cloud-based Electronic Medical Records (EMR)
• Widely used in LTACs and adapted to Medical Sheltering

Objectives

• Explain the importance and benefits of using an Electronic Medical Record (EMR)
• Successfully log in and out of the EMR system while maintaining data security.
• Navigate the Home Dashboard to locate key functions and features.
• Utilize the Quick ADT feature to admit, discharge, or transfer a resident.
• Create a new resident record following proper data entry protocols.
• Perform a search to locate existing resident records quickly and accurately.
• Access and update resident demographic information as needed.

Why Use an Electronic Medical Record (EMR)?

• HIPAA Compliance:
• Secure handling of patient data, reducing privacy risks.
• Fewer Errors:
• Automation of data entry and medication management minimizes manual mistakes.
• Faster Communication:
• Streamlined, real-time communication among care teams and departments.

How to Login to PCC

Logging In

• Log in:-> Navigate to the PointClickCare login page (pointclickcare.com)

Logging In

• Enter your assigned Username and Password in the designated fields unless Single Sign On is enabled.
• Username and Password may be different Live vs Training

• Note: You will be asked to create a strong password you can remember upon first login. DO NOT FORGET IT.
• Note: Never share your credentials.

MFA (Multifactor Authentication)

MFA IS REQUIRED IF:

TO USE MFA

• Secure Sign On (SSO) is not working
• If you enter PCC without using SSO (manually)

• If you don't have an Authenticator App, Download Google or Microsoft Authenticator
• Scan the QR Code provided by PCC with your phone camera
• Find the Authentication 6 digit number in the Authenticator App you chose
• Enter the Number into PCC when prompted

The Home Dashboard

• Navigation Bar: Provides quick access to different modules:
• Home
• Billing
• Care Services
• Insights
• Report
• Alert Icon : Notifies staff of critical patient information or pending tasks.

Admitting New Patients and Guests

This applies only to new accounts, not patient or guest returns or transfers in or out of the facility

Creating a New Patient Record Quick ADT(Admission, Discharge, Transfer)

Quick ADT Workflow: A streamlined process for managing resident admissions, discharges, and transfers.

Where to Find It: CARE SERVICES > ACTIONS > QUICK ADT

Usage Tips: Use for efficient resident entry during Triage, creating a new patient or changing their status

Quick ADT (QADT) Location for NEW Patients

• >Care Services 
• > Actions
• >Quick ADT

Creating a New Patient/GUEST Record Ensuring No Duplicate Record

• In the pop-up, enter only the required demographic information (Name, DOB)
• Confirm spelling, DOB and select >SEARCH
• The system looks for the same patient to avoid just a change in status
• Use ALL CAPS for guests
• Note: Pay close attention to common names and use as many identifiers as possible to ensure you're selecting the correct patient or guest

Creating a New Patient Record

• If there is no match for patient/guest entered, then press OK to add a new patient/guest to PCC.

QADT Step 1 and 2

2. Select Estimated Payer Type as Private

1. Action Code>Select Action Code >Admission[AA]

QADT  Step 3

Choose a Bed Location: Location>Magnifying Glass>Choose Bed

• Note: Alpha Beds are designated for Isolation

QADT Step 4

4. Select Primary Payer as status Guest or Patient

• This ensures the Patient vs GUEST assignment  is captured.
• Note: If “GUEST” type name in ALL CAPS (GUESTS will now be easier to locate in lists)

QADT Step 5/6

5. Ensure Required Fields Noted with a Red Asterisk are now complete 6. Fields not marked with an asterik but important to complete are

• Sex (M/F),
• Date of Birth, and
• Emergency Contact Information

Final Step ADT: Allergies

• Allergies

• If the allergies are unknown or not asked or available, leave as:
• To Be Determined
• If the patient reports no allergies select
• No Known Allergies
• Select
• Save

PCC TRIAGE INTAKE COMPLETED

• Patient or Guest is now moved to the assigned bed. If the patient has obvious signs of instability, radio call per protocol.
• Full Demographics and Charting should be completed at assigned bed.

• DO NOT DELAY MOVING THE PATIENT TO THEIR BED TO FINISH ALL DEMOGRAPHICS IN STABLE PATIENTS

Beyond QADT: Demographics

Completing Demographics Opt1

OPTION #1

• To Edit or Update the patient's demographic information:
• Care Services >People>Patient>(Choose Correct Patient!)>edit
• Note this must be done to show the admitting process as COMPLETE.

Completing Demographics Opt2

OPTION #2

• CareServices > People > Patient > (Choose Correct Patient) > Edit (Choose DEMOGRAPHICS)

Completing Demographics

• Complete the following:
• Any Required Red Asterisk Fields
• Middle Name (if applicable)
• Patient Type: Guest or Patient (If not captured in QADT)
• Preferred Name (if applicable)
• NOTE: There is no need to collect the following as we do not bill the patient.
• Medicare/Medicaid Information
• Social Security Number
• Insurance Information
• Resident Barcode Number

Completing Demographics

COMPLETE THE FOLLOWING:

• DOB (If not captured in QADT)
• Citizenship
• Marital Status
• Religion
• Occupation
• Allergies
• To Be Determined OR
• No Known Allergies
• Primary Language
• Interpreter Needed
• Education

Completing Demographics

DO NOT COMPLETE THE FOLLOWING:

• Discharge Date/Estimated Discharge Date
• Birthplace
• Preferred Pronouns
• Sexual Orientation
• Gender Identity
• Race

Completing Demographics

COMPLETE THE FOLLOWING:

• Next Physician Visit (If needed for a Follow-up, this is optional)
• All Consent Information:
• Consent Date
• Provider of Consent
• Name of Person Providing Consent (If Not Patient)
• Relation to Client: (If Not Patient)
• YES/NO (Allowing access to Medical Records)

Completing Demographics

DO NOT COMPLETE THE FOLLOWING:

• Last Physician Visit
• Last Order Review
• Next Order Review
• Waiting List

Completing Census

Completing Census

• After entering demographics within Care Services, you must finish by going to the Billing Tab
• Select the Dashboard under Financial Management
• Find your patient

Completing Census

• Find your patient
• Select update
• This opens a new window which must be saved

Completing Census

• Select Save
• This step moves the patient to a completed patient in Census.
• WITHOUT THIS STEP THE PATIENT REMAINS IN A TEMPORARY STATUS ONLY
• Ignore any Payer screen afterwards

Allergy Entry

Allergy Entry

• Access the Allergy Section:
• Located within the resident's chart,
• Open New
• Add Allergy Data: Enter all known allergies, including medications, food, environmental, and other substances.
• Severity: Document the severity of the reaction (e.g., mild, moderate, severe).

DIET ORDER ENTRY

Diet Order

• Most patients arrive to the shelter hungry
• Diet is entered via the Orders Tab
• ALLERGIES MUST BE IDENTIFIED FIRST TO ENTER PROPERLY

Adding a Diet

• Upon selecting Diet, an Orders Box Opens
• Select the Ordering Physician
• Select the Diet Type, Diet Texture, Fluid Consistency
• If the patient has a food intolerance add it to the Additional Directions
• Ignore Order Type

ENTERING MEDICAL DIAGNOSES

Important as diagnoses are linked to use of certain medications

Medical Diagnosis

• CareServices>People

Patient>Medical Diagnosis>New Diagnosis>Code

• Entering a medical diagnosis in a patient's chart is a critical step, as it guides treatment and ensures accurate record-keeping. 

Order - Entering Medications

Care Services>People>Patient>(Choose Pt)>ORDERS>New>Pharmacy

Enter Medication Details: Fill in the required information for the medication, including:

•Medication Name: The name of the medication. •Dosage: The prescribed amount of the medication. •Route: How the medication is administered (e.g., oral, injection). •Frequency: How often the medication is given (e.g., once daily, twice daily). •Schedule: The specific times the medication should be administered. •Start Date: The date the medication should begin.•End Date (or Duration): The date the medication should end, or the duration for which it should be given. •Ordering Physician: The name of the doctor who prescribed the medication.

Save the Order: Once all the necessary information is entered, save the medication order.

Confirm in eMAR: The medication order should now be visible in the resident's eMAR, ready for administration.

Entering Medications

Review of Medications

• Reviewing medication orders transcribed, for complete accuracy, is a vital step in ensuring medication safety and quality of care, helping to prevent errors, improve efficiency, and enhance communication within the healthcare team.
• Once orders are reviewed for accuracy, click the Acknowledge button.
• Note: Review any Black Box Warnings by clicking each alert in the Order Entry window before proceeding.

COMMUNICATIONS

This section is for Personnel to give notice between shelter personnel about Patient or Guest occurences like Case Management to evaluate or for activities that cross shifts and need reminders between personnel.

Communications Pt 1

Communications allows mesagging about a specific patient The Board is visible to other users

Communication Pt 2

• Enter the note regarding a patient or guest.
• Save to post

Communication Pt 3

• Do not delete messages unless on the wrong patient. Sunset by edit function to calendar date day prior. 

Communication Pt 4

Sunset by edit function to left of message on the Communication Board by setting Don’t Display Date to calendar date day prior to entry date or allowing to expire if it doesn't result in additional unnecessary responses to close.

Communications 24/72 Hour Summary Nurse Manager/Charge Nurse

• Care Services>Care Mgmt.>Summary Reports>Choose 24 or 72 Hour
• REPORTS include:
• New Admissions
• Discharges
• Patient’s On Leave
• Patient’s Returned from Leave
• Location of Empty Beds
• Resident’s Summary for Each Wing

ENTERING A PATIENT SCHEDULE

Used to enter offsite as well as onsite activities that are scheduled. This does not include facility events.

Patient Schedules

• Care Services>People>Patient>Calendar Icon on Patient Chart
• Used to schedule, view, and manage resident appointments and events. 
• It allows staff to track individual resident schedules,
• Aids in organizing activities, managing care plans, and ensuring timely delivery of services. 

Patient Schedule

• Select New and Enter the Details of the schedule

Patient Schedule

• Enter Details as Needed for the Team to be aware of Individual Patient/GUEST Schedule
• Particularly helpful for Dialysis

Progress Notes and Forms

Progress Note

A well-written progress note should include the following: Essential Details: Patient's name, date/time of note, reason for care, vital signs, test results, diagnosis, treatment plan, and patient response. Late Entries: Clearly labeled "Late Entry" with the actual date and time of the event being documented. Clarity and Brevity: Use concise, specific, and relevant language. Objectivity: Focus on factual observations, not personal opinions. Structured Format: Use frameworks like SOAP (Subjective, Objective, Assessment, Plan) or DAP (Data, Assessment, Plan). Timeliness: Document as soon as possible after the encounter. Safey Measures: Note any actions taken to ensure patient safety. Professional Language: Use terminology that is clear and appropriate for both healthcare providers and patients.

Progress Note Types

• Multiple Progress Note Types are available. Use the one that matches your function.
• Ensure if you are a Nurse use Nursing Progress Note, Case Management uses Case Management Progress Note, etc
• The Skin/Wound Note includes a map of the body. All others are Narrative.

Nursing Progress Note

• Care Services>People> Patient>Progress Note>New> Type: Nursing Progress Note

FormsCare Services>People>Patient>Forms:(Drop Down Box)>Choose Form from List>Save

The following forms must be completed during stay: PROVIDER

• Admission Intake Provider
• Discharge Provider Assessment

TRIAGE/WING NURSE/CASE MANAGEMENT

• Syndromic Surveillance Assessment
• Admission Intake Nursing
• Case Management_Intake_Access/Functional Assess
• Nursing Discharge Checklist
• Case Management_Discharge_Access/Functional Assessment
• Self-Administration of Medication Assessment (if self administering)

Strike Out

• Care Services > People > Patient > Progress Note (OR Location of Form) > View > Strike Out > Drop Down Box > CHOOSE Reason for Strike Out > STRIKE OUT
• When you strike out a document, it signifies that the content of the document is no longer considered active or accurate, but it is not deleted and is still visible, but with a line through it.

Electronic Signature

Electronic Signature

• Electronic signatures are used to ensure the integrity of the EHR, track documentation, and streamline healthcare processes.
• Note: All documents must be SAVED/SIGNED/LOCKED (e.g.: Admission Form) to be noted as COMPLETED.
• Note: An INCOMPLETE document cannot be SIGNED but can be SAVED to be completed at later time.
• An incomplete document will be noted with errors until all required fields are completed, and an ALERT will be displayed.

• Note: Use Password to Sign Document. Only 5 attempts given then our account will likely be locked for a period, such as 60 minutes. This is a security measure designed to prevent unauthorized access to your account and sensitive patient information. 

Managing the Care ProfileCare Services>People>Patient>Care Profile

• The Care Profile: A central hub for all clinical information related to the resident's care.
• Adding Therapies: Document physical, occupational, speech, and other therapies, including frequency and duration.
• Adding Devices: Record details of medical devices, such as pacemakers, prosthetics, or oxygen equipment, and their unique device identifiers (UDI).

Navigating the Alerts View

• Accessing Alerts View
• Designed for quick visibility into current and past alerts affecting care workflows.
• Locations Where Alerts Appear:
• Dashboards:
• Clinical Dashboard
• Resident Dashboard
• Specialized Modules:
• Weights and Vitals Portal: Flags exceptions like abnormal pain or vitals.
• ADT Notifications: Real-time alerts for admissions, discharges, and transfers

Data Quick Entry

Efficiently document routine patient data using a Batch Entry as opposed to going into each patient’s record individually:

Purpose:

•Immunizations •Weights •Vitals •Blood Sugar •Pain Level

Daily Quick EntriesCare Services > Quick Entry > Select Residents > Document and Save

• Care Team Visibility:
• All entries are immediately visible to the entire care team, ensuring real-time awareness of resident status.

Searching for a Resident

• Located right top of the dashboard for quick access
• Search Criteria:
• Search by Name: Enter the resident's full name or partial name.
• Search by Patient Medical Record Number (MRN)

Searching the List of Patients

• CARE SERVICES > PEOPLE > Patient > Choose Correct Patient from List

(Notice: All Patients includes New, Current, Discharged, and Waiting Patients. If Current patients is selected and patient was discharged, you will only see a search of Current patients and not “find” the patient. Best Practice: Search all Patients)

• Note: If full list of patients is not seen, click “ALL” button and a full list will appear.

Care Services

• CARE SERVICES is the most used tab in PCC
• It includes the following:
• People>Patients
• Actions>Quick ADT or New Patient
• Care Management>Dashboard, Calendar, Order Entry, Vitals, Lab/X-ray (if a local lab or X-ray provider integrates with PCC, Incidents
• Quick Entry> Immunizations, Wt, Temp, Pulse, RR, Blood Sugar, O2Sats, Pain Level
• Modules> eMAR

Using eMAR

• Navigating Electronic MAR (eMAR): Access the eMAR module to view scheduled medications and treatments.
• Documenting Medication Administration: Electronically record when medications are given, including dosage, route, and time.
• Medication Alerts: eMAR provides automated alerts for potential drug interactions, allergies, and overdue medications.

Alerts

• Care Services>Patient

Quick ADT - Transferring Patient Out to Hospital

• Care Services>People> Patient>Click on Correct Patient(Verify Patient’s Chart)>Hover on Care Services>Action>Quick ADT> TRANSFER OUT OF HOSPITAL
• Complete any other required fields and save the information.
• Note: Outcome of Transfer can later be filled in.

Quick ADT - Discharging Patient

• Care Services>People> Patient>Click on Correct Patient(Verify Patient’s Chart)>Hover on Care Services>Action>Quick ADT>Action Code>DISCHARGE
• Complete any other required fields and save the information. 

Care Management Nurse Managers/Charge Nurse

CARE MANANGEMENT tab consists of the following tabs:

Care Management Dashboards Nurse Manager/Charge Nurse

Care Services>Care Mgmt.>DASHBOARD Key Functions of the Dashboard:

• Notes number of ADTs
• Census
• Ability to Print
• Census Report
• Action Summary Report
• Incomplete Admissions

Facility Calendar

• Care Services>Care Management>Calendar
• This section is used for scheduling and managing facility-wide events, such as group activities, outings, and special events.
• Avoid adding information related to specific resident appointments or private information (HIPPA).

Incident Reporting

This module lives outside the medical record and is used to record and track significant events like falls with injury, deaths, medication errors, etc

Care Management Incident Reports

Used to document and track various events that occur within a healthcare facility, especially those that affect residents or staff. These reports serve as a formal record of the incident and are used for investigation, analysis, and improvement of processes to prevent future occurrences.

Examples of incidents that might be documented include:

Falls

Medication Errors

Delay in Treatment

Patient Altercations

Lack of Adherence to Standing Orders

Equipment Malfunctions

Unanticipated Death

Stage 3,4 Unstageable Pressure Ulcers

Incidents live in the Incident Report Module and are not included in the Medical Record: Incident reports are not part of the patient's medical record and should not be referenced within it however, a progress note of patient’s injury and intervention should be noted.

Incident Reporting

Incident Type is Selected

• ALL CAPS TYPES must be reported immediately to DSHS with crimes reported to local authorities as well
• An Incident Description followed by Injuries, Factors, Statements, Actions, and any Notes will be asked
• Only the Senior leadership should sign off and close
• Progress notes should address only medical concerns, not incidents

Care Management Nurse Manager/Charge Nurse

CLINICAL DASHBOARD The dashboard displays critical patient information, such as vital signs, medications, lab results, and care plan details, allowing staff to quickly grasp a resident's status.  Enhanced Communication and Collaboration: It facilitates communication and collaboration among care team members by providing a centralized view of patient information and facilitating information sharing.  Improved Care Coordination: By providing a comprehensive overview of resident needs, the dashboard helps care teams coordinate care plans and interventions more effectively, ensuring that residents receive the appropriate level of care.  Efficient Workflow Management: The dashboard helps streamline workflows by highlighting tasks that need attention and allowing staff to prioritize their work based on resident needs.

Transferring Patient Out or DischargeTransfer/Discharge Record

Nurses must ensure a “Transfer/Discharge Record” accompanies the patient for: 1. Care Coordination

• Ensures smooth transition between care settings.
• Provides the receiving facility with accurate, up-to-date information.
• Supports continuity and safety of care.

2. Accurate Resident Tracking

• Maintains correct resident status and location in the system.
• Helps manage census and facility occupancy effectively.

Discharge Workflow

• Entering Discharge Data: Accurately document the discharge date, time, destination, and discharge diagnosis.
• Completing Documentation: Ensure all outstanding tasks, progress notes, and orders are completed and signed.
• Medication Reconciliation: Reconcile all medications, providing the resident/family with a complete list and instructions.
• Ensure that ALL medications are received from Pharmacy and given to patient.
• Ensure all belongings and patient’s medical equipment are with patient at discharge.

Questions?