Assessments

Be aware that, although you can sometimes copy and paste information in PointClickCare, you must ensure that documentation is complete and accurate.

Risks associated with copying and pasting information into a resident record:

Resident safety and quality of care: identical wording could indicate failure to reassess.
Breach of resident’s privacy: if copying from another resident’s chart, omit any identification and verify accuracy.
Insurance fraud: identical language day after day or between residents is an indicator of fraud to Medicare and other insurers.
Denial of payment: identical language may lead to a refusal of payment upon chart review.

When copying and pasting, be sure to reassess and reword accordingly. If the resident’s condition is identical, it is still recommended to change some of the wording to avoid the above issues.

Be aware that surveyors might erroneously assume that Structured Progress Notes (SPNs) are the product of copying and pasting, so you may need to educate them.

An SPN is a template that pulls in information from the resident’s chart, and responses from an assessment.

If there is a question group in the assessment that only contains questions with multi-select check boxes, those responses pull into the SPN separated by commas.

Uniformity is sometimes viewed negatively by surveyors, therefore before locking an assessment, click View Progress Note and use the Comments section of the Structured Progress Note to personalize or add notes regarding the uniformity of language.

Skilled Nursing Facilities

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Assessments