For a CNA, POC usually means Point of Care, the module in PointClickCare where you document the care you give: ADLs, meals, fluids, vitals, bowel and bladder, behaviors, and more. You chart on a wall kiosk, tablet, or phone, at or near the resident's bedside. What you enter feeds the nurse's assessment, the MDS, the facility's Medicare payment, and the legal record.
Three meanings of "POC" in long-term care
Term | What it means | Who uses it |
|---|---|---|
Point of Care | The CNA charting module in PointClickCare and similar EHRs | CNAs, nurse aides |
Plan of Care | The resident's care plan: goals, interventions, and tasks | Nurses, MDS coordinators, the whole team |
Point-of-care testing | Bedside tests such as finger-stick glucose | Nurses and trained staff |
They connect: the plan of care creates the tasks you see in Point of Care.
What CNAs document in POC
ADLs: bed mobility, transfers, walking, toileting, dressing, eating, oral and personal hygiene, and bathing
Nutrition: meal intake as a percentage, supplements, and fluid intake in mL
Elimination: bladder and bowel continence and output
Vitals and weights: when assigned
Skin and positioning: repositioning times and skin concerns reported to the nurse
Behavior and mood: observed behaviors and responses to interventions
Safety: fall precautions and any refusals
Change in condition: alerts such as INTERACT's Stop and Watch, if your facility uses it
How POC charting works, step by step
Log in at a kiosk or on the mobile app with the username your facility issued. Never share it; every entry is stamped with your name and time.
Open your assignment. You'll see your residents and which tasks are due or overdue this shift.
Check the care plan or Kardex before giving care, so you know transfer method, diet, and precautions.
Give the care, then chart it right away, choosing the response that matches what happened.
Document refusals and "not attempted" reasons instead of skipping the task.
Report changes (new skin areas, falls, appetite drops, confusion) to the nurse, and use the alert task if one exists.
Clear your due tasks before shift end and log out of the kiosk.
Section GG: the ADL scale CNAs need to know
CMS retired MDS Section G and moved function coding to Section GG on October 1, 2023. GG codes usual performance over the assessment period, not the most help given once. The key question is how much of the effort the helper provided.
Code | Level | What it looks like |
|---|---|---|
06 | Independent | Resident completes the activity alone |
05 | Setup or clean-up assistance | You only set up or clean up before or after |
04 | Supervision or touching assistance | Verbal cues or steadying touch; no lifting |
03 | Partial/moderate assistance | You do less than half the effort |
02 | Substantial/maximal assistance | You do more than half the effort |
01 | Dependent | You do all the effort, or it takes two or more helpers |
When an activity didn't happen, use the right reason code: 07 resident refused, 09 not applicable (didn't perform it before this illness), 10 not attempted due to environmental limits, or 88 not attempted due to medical condition or safety concerns.
Example 1: You set out clothes and the resident dresses their upper body alone: 05. Example 2: You lift the resident's legs into bed while they push up with their arms, and you're doing most of the work: 02. Example 3: Two staff use a mechanical lift for a transfer: 01.
Why accurate POC charting matters
Resident care: nurses spot declines from your trends in intake, mobility, and continence.
MDS and payment: Section GG drives the functional score in the Patient Driven Payment Model and in state Medicaid systems that use it. Under-documenting help lowers payment the facility earned; over-documenting creates audit risk.
Survey and legal record: CMS requires complete, accurate resident records (F842). In court and in surveys, care that isn't charted is treated as care that wasn't given.
10 POC charting tips for CNAs
Chart in real time, not at the end of the shift.
Never chart care before you give it.
Code what the resident did this time, not last week's answer.
Use refusal and not-attempted codes instead of leaving tasks blank.
Record meal intake by the percentage actually eaten.
Record fluids in mL, not cups.
Don't copy the same answer across every resident or shift.
Follow your facility's late-entry policy if you must chart afterward.
Never log in for, or chart for, another aide.
Log out of shared kiosks every time.
POC login problems
PointClickCare accounts are created by your facility, not by individual CNAs. Use the login link or kiosk your facility provides. For locked accounts or expired passwords, ask your supervisor or the facility's PointClickCare administrator. Avoid third-party "login" sites.
FAQ
What does POC stand for for CNAs?
Usually Point of Care, the CNA documentation module in PointClickCare. In care planning, POC can also mean Plan of Care.
Is POC the same as PointClickCare?
POC is one module inside PointClickCare. Nurses use other parts, such as eMAR and assessments.
Do CNAs still use Section G?
No. CMS retired Section G on October 1, 2023. ADL function is now coded with Section GG.
What if a resident refuses care?
Document the refusal with code 07, offer again per policy, and tell the nurse.
Can I chart for a coworker?
No. Each entry must come from the person who gave the care, under their own login.
Sources: PointClickCare Point of Care overview · CDPH AFL 23-32 on MDS v1.18.11 · Maryland Medicaid on Section G removal · Skilled Nursing News on Section GG effort rules · SimpleLTC GG scoring overview
