Point Click Care Question

Kamyo · Feb 4

Rochasie said:

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?

Yes, there is likely some required documentation that has not been entered. If the order requires a temp, BP, HR, BG level, etc to be entered, and it's not entered, it will not save. Go back and click 'Y' then select the documentation tab. Enter the documentation, click record, and then you should be able to change it from yellow to green.

Kamyo · Feb 4

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?

No need to fear. Either your work friend or the folks who were bragging aren't being honest. NOBODY is able to delete a non-draft, signed progress note. Not management, not IT. If you don't believe me, click the 'Q' at the top of your header and select the option that says 'find answers.' In the search box, type in "delete Progress Notes." The very first article states expressly that Progress Notes cannot be deleted. The best one can do is strike out a note, which only the author of the note can do. However, if it is a draft note; these CAN be deleted by anyone with permission to do so. We're talking about a legal record here. If PCC allowed completed Progress Notes to be struck out, they'd probably be in a world of hurt from the related legal trouble.

Kamyo · Feb 4

carrie02 said:

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.

Does anyone else have your password? Perhaps looking over your shoulder as you typed it, or is it easy to guess, or was their a conversation about passwords where you maybe gave a hint to others?

Even so, the most anyone could do is what you yourself could do--strike out the note. Click 'view all' to see if it was struck out. Double check all your horses before deciding the zebra caused the hoofprints.

In the case of Assessments/Forms, those CAN be deleted by those given that permission. Though, I'm sure PCC can track those and provide a who/when report, for a fee of course.