Point Click Care Question

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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?

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What Members Are Saying (AI-Generated Summary)

Members are discussing issues with the Point Click Care system, specifically regarding the deletion of nursing progress notes. Some members believe that certain individuals within the organization have the ability to delete entries, while others suggest that progress notes cannot be deleted, only struck out. There are concerns about the security and integrity of the system, with some members seeking advice on how to address these issues.

Specializes in PACU, pre/postoperative, ortho.

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).

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Specializes in OR/PACU/med surg/LTC.

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.

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Specializes in Psych, Addictions, SOL (Student of Life).

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.

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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.

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did you perhaps put it under a different patient?

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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.

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Specializes in PACU, pre/postoperative, ortho.

Curious...did you ever figure out what happened?

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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?

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Specializes in Long-term care.

I am thankful to find this question. I thought I was alone with this problem. It's been theee years since this question was posted but I will tell you what I know.  Yes it is possible to have your progress note in the EMR (pointclickcare) deleted. Within the organization you work for certain people have that ability/access in the program to do so. I thought I was losing my mind when I first noticed my charting no longer existed. When this happened I told a work friend in confidential. That person told me weeks later a nurse that has worked for the facility for a long time was bragging about how herself and one other nurse, who is in administration, have the ability to delete any entry they decide to. I'm in a sticky situation. I live in a rural area and if I say anything about what is happening, I'm fearful I will be blacklisted from getting another job where I live. I wondered how to find out if this was something all facilities using PCC do?  Is it a common secret?

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Same here. I'm so fed up. I work to hard and my job requires hours of documentation before I leave the building I triple check everything even screen shots but it's too much work to prove you did it. I absolutely thought I was losing my mind. Totally wrong and making me redo my work keeps me late at work 

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Specializes in Vents, Telemetry, Home Care, Home infusion.
Night nurse said:

I am thankful to find this question. I thought I was alone with this problem. It's been theee years since this question was posted but I will tell you what I know.  Yes it is possible to have your progress note in the EMR (pointclickcare) deleted. Within the organization you work for certain people have that ability/access in the program to do so. I thought I was losing my mind when I first noticed my charting no longer existed. When this happened I told a work friend in confidential. That person told me weeks later a nurse that has worked for the facility for a long time was bragging about how herself and one other nurse, who is in administration, have the ability to delete any entry they decide to. I'm in a sticky situation. I live in a rural area and if I say anything about what is happening, I'm fearful I will be blacklisted from getting another job where I live. I wondered how to find out if this was something all facilities using PCC do?  Is it a common secret?

  HIDDEN for a reason by QI mgmt, but never entirely deleted may occur WIth proper procedure and nurse notification: e.g topic should be in incident report. Or content needs physician review prior to patient viewing information.  Outright deletion NOPE!

What is your facilities POLICY on PCC documentation and edits??  --  I'd alert risk management to the concern.

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