How to document patient education effectively
Records prove teaching and communication
Surveyors for the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Health care Organizations are looking for proof of patient education. While policies, procedures, teaching sheets, and programs all point to a patient education program, they don’t provide enough evidence by themselves. To prove interdisciplinary teaching takes place, it must be documented.
"The No. 1 way the Joint Commission determines if you met the standards is to look at documentation in the patient record. The main evidence of patient teaching and assessment is in the patient record," says Louise Villejo, MPH, CHES, director of patient education at the University of Texas MD Anderson Cancer Center in Houston.
When preparing for an accreditation visit from the Joint Commission, MD Anderson Cancer Center hired a company to conduct a mock survey to see if the health care facility was meeting Joint Commission standards. The consulting firm noted that although teaching programs and process were in place, documentation of many components of education was inconsistent and there was no continuity among disciplines.
To remedy the problem, the patient education committee decided to revamp the documentation form and examine the barriers to documentation.
Documentation on an interdisciplinary patient/ family education record at Shands Hospital at the University of Florida in Gainesville helped show a Joint Commission surveyor there was a collaborative effort toward patient/family education. The form was developed by an interdisciplinary team according to Joint Commission standards.
"Development and implementation of the form helped to demonstrate compliance," says Kathy Conner, ARNP, MN, CPON, coordinated care manager of nursing and patient services at Shands.
While a good interdisciplinary documentation form is definitely a piece of the puzzle, the form in and of itself will not prompt disciplines to document, says Sandra Cornett, RN, PhD, program manager of consumer health education at The Ohio State University Medical Center in Columbus. There is no proof of interdisciplinary teaching and communication if the form is not used.
Therefore, Cornett recommends you make sure you have a form that streamlines and facilitates patient education. However, once the form is in place, there are other steps that must be taken to make sure the form is used. They include:
• Provide adequate training.
To implement the new form created at MD Anderson, all disciplines had to participate in a mandatory inservice. A poster session that showed the use of the form and required a self-test at the end was used to provide flexibility and accommodate the varied schedules of busy staff.
Inservices on units targeting various disciplines also were conducted. Chart audits coincided with staff education to determine which areas were not documenting patient education effectively.
"It is a continuous education process. We can’t expect staff to go through one inservice and document on the form 100% of the time," says Villejo.
To educate staff about the patient teaching process, the patient education committee at York (PA) Health System created a self-learning packet, says Donette Lasher, MAT, patient education coordinator for the system. The packet included information on assessing the patient for readiness to learn, creating a plan for education, implementing the plan, evaluating the teaching, and documenting it. The form also was covered in the packet.
In addition to completing the self-learning packet, all nurses had to attend an inservice that included an explanation of why the form is important, how it is used, and a case study. "We taped the program to make sure that everyone could attend an inservice," says Lasher. Following the teaching, nurses were required to take a test.
• Create a mindset for documentation.
If you want staff to document patient education, managers must place a value on it, says Cornett. Teaching — and documentation of that teaching — should be part of a staff member’s job description. Also, documentation of patient education must be part of an employee’s performance appraisal.
While there should be consequences for poor documentation, staff should be rewarded if they do a good job, according to Cornett. She recently implemented an incentive program in which staff receive a button that reads, "I educated the write way," for documenting patient teaching. The rewards are distributed following chart audits that are conducted every three months.
• Discover barriers to documentation.
Interview staff to determine what barriers there are to documentation of patient education, advises Villejo. For example, one problem at MD Anderson was the form’s location. The nursing staff wanted it at the patient’s bedside for convenience, yet when the patient went to another area, those disciplines couldn’t document because they didn’t have the teaching record. "We made it a rule that it had to stay in the chart," says Villejo.
For more information on documentation of patient education, contact:
Kathy Conner, ARNP, MN, coordinated care manager, Department of Nursing and Patient Services, Shands Hospital at the University of Florida, 1600 Southwest Archer Road, Box 100335, Gainesville, FL 32610. Telephone: (352) 395-0392. Fax: (352) 395-0253. E-mail: [email protected].
Sandra Cornett, RN, PhD, program manager, consumer health education, department of consumer & corporate health education & wellness, The Ohio State University Medical Center, 1375 Perry St., 5th Floor, Columbus, OH 43201. Telephone: (614) 293-3191. Fax: (614) 293-3690. E-mail: [email protected].
Donette Lasher, MAT, patient education coordinator, York Health System, 1001 South George St., York, PA 17405. Telephone: (717) 851-3081. Fax: (717) 851-3049. E-mail: [email protected].
Louise Villejo, MPH, CHES, director of patient education, University of Texas MD Anderson Cancer Center, 1515 Holcombe, Box 21, Houston, TX 77030. Telephone: (713) 792-7128. Fax: (713) 794-5379. E-mail: [email protected].
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