Nurses General Nursing
Published Jul 6, 2015
carrie02
3 Posts
Has anyone used the Point click care system? I was wondering if it is possible for someone to delete a nursing progress note from the system. I just found that one of my nursing notes is missing from the system and I know I signed it. Has this happened to anyone else?
RainMom
1,114 Posts
Not familiar with that system but I suggest contacting IT. They should be able to see if the chart was edited or deletions made (& by whom).
wanderlustnurse88, RN
198 Posts
From my experience, only the writer can strikeout the documentation but even then, it is still shown but with a line through it. Did it maybe not save. Sometimes the draft gets saved and it shows up at the top of the progress note.
hppygr8ful, ASN, RN, EMT-I
4 Articles; 5,073 Posts
Progress notes can be struck out but not deleted - It's possible you did not save - of you did and the computer hiccupped and didn't catch it. The program has some bugs in it as I just redid a whole set of admitting assessments that did not lock.
I have contacted IT. Waiting for a reply.
I also know you can strike out a note but it will still show up when you hit view all but with a line through it. My note is completely gone. I don't save anything as a draft. I write down my thoughts on my report sheet for the night and save them so I have a log of what I did or didn't do b/c my nights tend to run together. When I type something in the computer it is signed and locked right away and I check to make sure it is there. I know it was there the night saved it. I just happened to be checking back on lab work and came across this as a accident that my note is now gone from the computer.
morte, LPN, LVN
7,015 Posts
did you perhaps put it under a different patient?
I will check out the other patients on the date in question to make sure but I'm 99% sure I didn't put it under another patient.
Curious...did you ever figure out what happened?
Rochasie
I use point click care at work, when I try to save after selecting "yes" for giving medications, the screen come back to me unsaved. My selection does not turn green it stay yellow. Any advice?