Electronic health records tend to drift. A workflow created for one problem gets copied to the next. Staff who left years ago still have accounts. A report someone requested once keeps running, unread. Small compromises accumulate until the system feels harder than it should.
A yearly optimization review is a planned chance to reset. This checklist is written for administrators, directors of nursing and EHR administrators using PointClickCare or a similar system. It stays general, since options differ by organization and vendor.
Pick a small team: someone from nursing, someone from business office or medical records, your system administrator and, if possible, a frontline user from each shift. Set a few hours across a couple of weeks, and gather input from staff before the meetings.
Ask staff where the system slows them down. Then look at:
Documentation steps that are duplicated, unclear or rarely used.
Handoffs between nursing, therapy, dietary, social services and the business office.
Admission, transfer and discharge processes, including what is entered by whom and when.
Orders and medication workflows, where delays or workarounds appear.
Paper that still exists alongside the electronic record, and whether it needs to.
Downtime procedures, to make sure they are current and practiced.
For each issue, decide whether the fix is a setting, a training topic or a policy change. Discuss any configuration changes with your vendor or administrator, and test them before rollout.
User access creates both risk and frustration.
Export the user list and compare it against current staff. Disable accounts for departed employees and long-inactive users.
Check that each role has only the access its duties require.
Review special privileges, including administrative rights and the ability to override or edit sensitive items.
Eliminate shared logins.
Confirm that multi-factor authentication is used where your vendor and policy support it.
Review how outside users, such as physicians, consultants and agency staff, are granted and removed.
Look at audit logs for unusual access patterns.
HIPAA's Security Rule expects access management and periodic review, so document what you checked and changed.
List the reports your team runs regularly. Who reads each one and what decision does it support?
Retire reports nobody uses.
Ask what questions leaders cannot currently answer, and find out whether existing data can answer them.
Check that definitions, such as census or overdue documentation, match across reports.
Verify scheduled reports still go to the right people.
Sample records for common problems: missing information, inconsistent entries, duplicate residents or outdated contacts and payer details. Fix patterns at the source through training, required fields or clearer procedures.
Which topics generate the most helpdesk or supervisor questions?
Does orientation reflect how the system is used now?
Are agency and new staff getting a quick reference?
Is there a go-to person on each shift?
Have you shared updates after vendor changes?
Short refreshers, tip sheets and shift huddles often beat long classes.
List the systems connected to your EHR, such as pharmacy, lab, billing and reporting tools, and check each is still needed and working as expected. Test devices at the point of care. Walk the building for Wi-Fi dead spots, check battery life and replace failing equipment.
Confirm backups or vendor recovery arrangements, review how quickly you could operate on paper, and make sure your contact list for the vendor and IT support is current. Include the EHR in your HIPAA risk analysis.
Sort findings into quick wins, projects and items to monitor. Assign owners and dates. Share the plan with staff so they see their feedback produced results. Pick a small number of changes, since too many at once overwhelm users.
Revisit the plan at the next quarter. Measure what you can, such as overdue documentation, helpdesk tickets and staff feedback.
UnityCare IT can help with the technical side of your annual review: user access audits, device and Wi-Fi checks, security reviews and working with your EHR vendor. If you would like a partner to help run the process, we are glad to help.
Keeping PointClickCare and other EHR systems fast, connected and available.
Call or text: 405-285-3845
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Existing customers: support@unitycareit.com
Address: UnityCare Technologies, 2524 N Broadway Ste 554, PMB 947974, Edmond, Oklahoma 73034-4172