[1] Clinical documentation is a record of the critical thinking and judgment of a health care professional, facilitating consistency and effective communication among clinicians.
[4] Such documentations provide evidence regarding safe, effective and ethical care and insinuates accountability for healthcare institutions and professionals.
Furthermore, accurate documents provide a rigorous foundation for conducting appropriate quality of care analysis that can facilitate better health outcomes for patients.
[5] Thus, regardless of the format used to capture the clinical point of care information, these documents are imperative in providing safe healthcare.
[13] Mobile technologies such as personal digital assistants (PDAs), laptop computers and tablets enable documentation at the point of care.
[14][15][16] PDAs are more functional for low volume and simple data entry and are preferred for their lightweight, portability and long battery life.
Furthermore, embedded algorithms may be chosen for people of certain age and weight to further support the clinical point of care interaction.
[20] Mobile devices and tablets provide accessibility to the Electronic Medical Record during the clinical point of care documentation process.
[21] Mobile technologies such as Android phones, iPhones, BlackBerrys, and tablets feature touchscreens to further support the ease of use for the physicians.
A delay between face-to-face patient care and clinical documentation can cause corruption of data, leading to errors in treatment.
[10] Giving clinicians the ability to document clinical information when and where care is being delivered allows for accuracy and timeliness, contributing to increased patient safety in a dynamic and highly interruptive environment.
[25][26] Ineffective communication among patient care team members is a root cause of medical errors and other adverse events.
Numerous point of care documentation systems produce data redundancies, inconsistencies and irregularities of charting.
Conclusively, continued efforts are being made to adopt charting of patient information in electronic format to improve the quality of clinical point of care services[33]