Point of Care Documentation in Pediatric Therapy

What is the definition of point-of-care documentation?

In essence, point-of-service documentation is documenting a session AS IT HAPPENS. That means you must complete your occupational therapy treatment daily note during the session.

Point of care (POC) documentation is defined as documenting a clinical medical encounter and interacting with and providing care to patients at the same time. POC documentation is supposed to enable clinicians by decreasing time spent on documentation and allowing for more time for patient care. But is that the reality?

With the pediatric population that can be very difficult. As we know kids are not always predictable and many of the children we serve have intense needs and behaviors. In reality, I have seen POC documentation as setting the child up with an activity at the end of the session at a table while notes are completed. Which can be difficult with many children, including those with Autism.

Other Medical Settings that use Point of Care Documentation

Many other medical professionals are also using PoC documentation such as doctors, nurses, physical therapists, and many more.

Have you seen a medical practitioner look more at their computer than at the patient during your appointment? Many settings use point-of-care documentation such as doctor's offices. But how has that made you feel?

Have you had to “set up” a patient with an activity to complete a note?

This is really common when working with the adult population. But is it really possible with pediatrics? Is it even a good idea?

Where have I personally been asked or required to do PoC documentation?

I worked in a setting that was part school and part medical model. In this setting, they were using all 30-minute sessions and required POC documentation. In many things, in this setting, I questioned if the best practices were being followed for the children. The POC documentation was definitely questionable. Most therapists were setting the child up with a puzzle at a table for the last 5 minutes of the session to complete the daily treatment note.

Where does point of care documentation work?

POC documentation works when you have a client who can be more independent. I have successfully completed POC documentation during teletherapy sessions with middle and high school-age students.

Has the shift to EMRs increased point-of-care charting?

In many settings, the answer is yes. It is much easier to complete a point of care documentation therapy note during a session with the use of a computer and an electronic medical record (EMR).

What are the benefits of point of care documentation?

The benefits of POC documentation are mostly for the clinician and facility.

They include:

• Documentation is completed quickly
• Documentation is always on time.
• Less paperwork for the clinician to complete outside of treatment times
• Increases productivity rates with less indirect treatment time
• Decreases work taken home
• Decreases hours work
• More accurate documentation

What about the negatives?

The negatives include:

• Time spent on documentation during the session
• Less focus on the client during documentation time during the session
• The client being “set up” with an activity while clinician completes paperwork
• Increased pressure to be “productive”
• Less time during a session to be present
• Less time during a session to problem solve and complete activity analysis

Best Practices for Pediatric Occupational Therapy Daily Notes

Each setting, practice, and the state has its own requirement for the deadlines for completing daily notes. This includes not only writing them but signing and finalizing them as well. So be sure to check with your employer about any requirements but in my experience, as a practice owner the following should guidelines should be followed at a minimum:

• Daily notes completed SAME Day
• Daily notes finalized by Friday evening
• Evaluations scored and drafted by Friday evening
• Evaluations should be completed and signed by end of the weekend. 1-week completion time maximum.

For the best work-life balance, ALL documentation should be completed by Friday evening, but in reality, I was able to complete all notes during the work day and evaluations after work hours.

Summary

While point of care documentation is possible in the pediatric OT population, the benefits to patient care are questionable.

Have you worked in a setting that required or encouraged point-of-care documentation? Did it work for you? Leave a comment below!