Point Click Care Question

RainMom · Jul 6, 2015

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 · Jul 6, 2015

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.

allnurses Guide · Jul 6, 2015

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.

carrie02 · Jul 7, 2015

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 · Jul 7, 2015

did you perhaps put it under a different patient?

carrie02 · Jul 7, 2015

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.

RainMom · Jul 23, 2015

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

Rochasie · May 15, 2016

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?

Night nurse · Sep 29

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?

Theresa Fout · Oct 25

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

Home Health Columnist / Guide · Oct 26

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.