Point Click Care Question!

[kjwrn]

Re: Point Click Care

Have Question about Point Click Care!

When entering MD orders in Batch entry (Co is just starting/training in system) when you get done with the med our 'paper' orders have the reason for the med such as constipation, HTN, CHF, etc.) When charting this a drop box pops up and you have to choose from the above dx's for reason med is given...(not everything is entered as I found constipation issing from 1 dx...but...do you choose the best fit? for instance...a pain med on our paper orders states it is given for 'shulder pain'....shoulder pain was not a listed dx/ICD-9 but osteoparosis was...(yet there is an ICD-9 for shoulder pain as I saw it on another patient...) for all I know this person's pain could be muscle related and not bone....

Won't I be aking more work for the Med Records Dept when they have to go back and fix these? I asked this Q today and one of the Med Records girls got tisky...I'd rather do something right the first time...and am not getting answers...also...I have been out of nursing for some time and have never passed many of these meds...still learning them...I guess Ishould have a med book handy when doing this?

Am confused and would appreciate any help and/or tips as I am not getting it from the staff.

I looked for tools to this system online but have been unsuccessful to date.

To make atters worse, when the 1st training took place (overview) everyone who should have been there, like myself was not scheduled. The directions we were given are written as if you know what you are doing already...not for a newbie to the system....

Appreciate any/all help!

Thanks

KJW

[Talino]

Softwares' online help, if provided, would only be available if you're a registered user.

There must be an option to manually enter an ICD9 if none of the choices fit. That is likely the case when the shoulder pain ICD9 is present on another patient -- 719.41 was entered manually. Personality aside, it is the responsibility of the computer administrator to update the ICD9 library whenever a code needs to be added or deleted.

Choosing the most relevant ICD9 should be sufficient. Enter the specific pain location in your nurse's notes.

Asking to learn is a humbling experience. Don't hesitate! Like Forrest Gump said, "Stupid is..."

[kjwrn]

Thanks...here is the problem albeit good as a control measure...only the Medical records dept will have access to entering the ICD-9 numbers...we only have the 'drop' down list that they previously entered to choose from...and I was trying to avoid leaving it blank or placing 'HTN' in that column....(knowing that seizure meds are not just used for seizures....)

Thanks!

[lanstanLVN]

My Company currently uses VistaKeane software, and will be changing over to Point Click Care before the end of the year. The problem of which you speak had come up with VK, and we noted there was an "indication for use" field that we could choose - for the instances when someone has a headache, you wouldn't have to give an ICD-9 for a "temporary" problem that could be remedied with a simple dose of Tylenol. I certainly hope there is a simular choice in PCC. I will be watching all posts regarding it so, as to learn all I can!

[salexander77]

I was JUST going through this same situation today. I'm not only new to Point Click Care (since we are JUST getting this in our LTC facility)...I'm also a new nurse. So, unfortunately I had many questions. I decided to sign up for some OT b/c they needed the POA's that were in the chart to be entered into the system. I got to this same section and wasn't sure what to put. I ended up just putting a space and leaving it blank. I don't know if that was correct or not (as I couldn't get ahold of ANYONE to help me) but I figured someone didn't put that information on the original document and as a nurse, I'm not allowed to dx so I wasn't going to put anything in incorrect. Like I said...I don't know if that was correct.

Best of luck and keep me posted if you find any answers and of any other helpful hints :)

Sarah