Articles

Health Literacy

Making Sure It Works: Documenting Patient Education

Article from the Boston Globe’s On Call Magazine, January 2000

By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

Not only do health professionals need to be excellent teachers, they must also be attentive to how they document what they have taught.

In her book The Practice of Patient Education (1997, Mosby-Year Book), Barbara Redman says, “Patient education is now well accepted as an essential part of the practice of all health professionals.” But patient education is more than just teaching facts and demonstrating skills. It is a two-way conversation in which patients and clinicians learn from each other and is an essential component of good patient care. An important step in patient education is good documentation.

Anne Marie Haber, RNC, a medical-legal consultant, says that documenting patient education promotes continuity and consistency in care, improves efficiency, and minimizes professional liability.

Consistency Creates a Foundation

Annie and Bob are parents to Claire, a baby born with a tracheo-esophogeal fistula. With this fistula there is a connection where there isn’t supposed to be one between the baby’s windpipe and the swallowing part of her throat. Claire has already had surgery to insert a tracheostomy that allows her to breathe and will need future surgery to complete the repair. Although Annie and Bob are scared and overwhelmed, they must learn how to safely and independently care for their baby. Through patient education, Annie and Bob will learn about their baby’s condition, observe tracheostomy care and practice it under supervision, and problem-solve what to do in an emergency.

“Consistency builds a strong foundation,” says Haber. Although clinicians may vary in how they provide tracheostomy care, it is important that Annie and Bob see the procedure done the same way each time. The documentation should note specifics about the methods that clinicians use, so that different clinicians can demonstrate the exact same procedure. Through this consistency, Annie and Bob can acquire a strong base in their knowledge of ways to care for their baby.

Avoiding Redundancy Leads to Efficiency

Careful documentation can also save time and avoid unnecessary repetition. If, for example, Annie and Bob see a video on tracheostomy care early in their baby’s hospitalization, they may not need to see it again. Without a note in the chart stating that they have already seen the film, it is quite possible that another clinician would show them the film for a second time.

When the patient education is documented, however, all clinicians on the treatment team would know that Annie and Bob have already seen the film and know that they are ready to observe and practice these techniques. In this instance, documentation of patient education helps to make the best use of everyone’s valuable time; clinicians continue to teach essential new information, and Annie and Bob remain attentive to the education they need the most.

DocumentationHelps Define Liability

In addition to enhancing patient education, careful documentation can also minimize professional liability, Haber says. She says that the documentation should not only include specifics about what topics were taught, but also include the patients’ responses to this education. For example, in the unfortunate event that Claire stops breathing once she goes home, Annie and Bob might claim they were never taught what to do in this type of emergency. Haber says that medical and legal professionals need only look in the medical record and find the dates that the parents had seen the videos, practiced tracheostomy care under supervision, and stated confidence in their ability to carry out these procedures at home.

Five Steps for Effective Documentation

Continuity and consistency of care, improved efficiency, and decreased professional liability are all benefits of documenting patient education Here are five things you as a healthcare professional should do to ensure proper documentation:

1) Use a standardized form.  Standardized forms, sometimes called “teaching tools,” have designated areas for specific information and can be an efficient way to quickly find important information. While they may have certain drawbacks resulting from multiple contributors, abbreviations, and limited space, they still have major advantages over narrative progress notes. In addition to providing an easy way to scan for information, forms also have designated areas to highlight key concepts, such as learning preferences, communication barriers, curriculum, responses, and further teaching needed. Making use of these areas will help ensure continuity in the education process.

2) Document formal and informal teaching. Formal teaching is often thought of as curriculum that is taught at a designated time, perhaps prefaced by a clinician saying “Now I’m going to teach you about….” Informal teaching, on the other hand, is teaching that happens on an on-going basis. For example, when Annie and Bob are feeding Claire, they are taught how to burp the baby, provide proper head support, and assess if she has a swallowing problem. Both formal and informal teaching are essential to patient education, and should be documented in the chart.

3) Describe the response of the learners. Patient education is more than what the clinician says or does; patient education is what the learner learns, and this should be carefully noted in the medical chart. In addition to a brief description of the topics covered, documentation should include a note about the interaction/response of the learner. In the case of Annie and Bob, this would include notes such as “Mother described…,” Father demonstrated…,” or “Parents asked.…” Patient education documentation should include information about the learner’s reactions and feelings as well as responses to open-ended questions.

4) When possible, put copies of educational materials in the chart. Ideally, copies of the actual teaching materials should be included in the medical record, says Haber. If it is not possible to put in the actual documents, describe the materials that were given out and encourage the patient or family to show them to their other clinicians. Detailed information about the teaching materials helps with the continuity of care, avoids unnecessary repetition, and helps to build on lessons already learned.

5) Update the teaching plan. As patient education is an ongoing process of learning and teaching, the patient’s medical chart should include space to update the teaching plan and include information about further learning needs, effective teaching techniques, and recommendations for the next steps. With this updated teaching plan, clinicians have the tools they need to educate patients, and patients remain stimulated and challenged by learning new information they most need to know.

How to Find Out More

Anne Marie Haber, RNC, is a medical-legal consultant who works with attorneys who need to understand medical records. She can be contacted by sending an E-mail message to info@AMHaber.com.

Printed Resources

  • Fischbach, F. (1991). Documenting Care: Communication, the nursing process and documentation standards. Philadelphia: F.A. Davis Company.
  • Iyer, P. & Camp, N. (1991). Nursing Documentation: A nursing process approach. Boston: Mosby Year Book.
  • Meiner, S. (1999). Nursing Documentation: Legal focus across practice settings. Thousand Oaks, California: Sage Publications.
  • Rankin, S. & Stallings, K. (1996). Patient Education: Issues, principles, practices (3rd ed). New York: Lippincott.
  • Redman, B. (1997) The Practice of Patient Education, Mosby-Year Book, Inc.

Article reprinted with permission from On Call magazine and published by a division of Boston Globe Media.