Page 7 - Pointcare Rehab Process and Tips

Review Medical Record OUTSIDE of a visit

From the Rolling Calendar screen, click on the Menu (3 vertical dots at top right) and click on Medical Records. Find and
select the patient’s name, then click on a patient’s visit(s).

History- viewing
Client Snapshot; Attachments; Coordination Notes; Visit Notes

o Client Snapshot: It is in green text. This section holds much patient information all in one spot.
• The Medical Record is viewable if staff are assigned to the patient’s care team.
• The Medical Record is viewable on PointCare for 14 days after death or discharge.
• The patient’s HCHB Medical Record # is located in Menu > Medical Records > Demographics> Personal
• The patient’s care types are located: Menu > Medical Records > Clinical Information >Care Type
o Insurance information and managed care authorization:
 history section of a medical record >Demographics > payor source
 View patient’s HCHB medical record number in the Client Reference tab on the bottom of the
patient’s home page.

Features-doing (Use this section to add Coordination Notes, add New Orders to update Calendar/ freq, add meds or
labs)
• You must scroll all the way down and expand the “Features” Section.

Visit Note Documentation

Start your visit note once you are in the patient’s home, NOT BEFORE!

The red exclamation point indicates that the clinician needs to view the Client Snapshot before starting the visit. The
Client Snapshot may include important info regarding the patient, e.g. vital signs parameters, treatment precautions,
etc.

The red exclamation point will NOT go away.

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