Reinforce good patient ed documentation practices

Review of techniques helps get the job done right

At Children's Healthcare of Atlanta, a special team called the documentation council routinely reviews a number of medical record forms, including the interdisciplinary patient and family education record.

In addition, the council completes chart audits monthly on each nursing unit and clinical department, such as nutrition or physical therapy. Certain staff members from these units or departments also are responsible for auditing charts.

Those who audit the charts have a list of particular items they look for, such as whether a patient's name and medical record number is on each page, if patient education is documented, and whether the handwriting is legible.

"They have a set of [Joint Commission on Accreditation of Healthcare Organizations] specifics and they go through those indicators and determine whether or not the medical records have them," explains Kathy Ordelt, RN-CPN, CRRN, patient and family education coordinator at Children's Healthcare of Atlanta.

The results of the audits from each department are given to the manager who addresses compliance issues. The system leaders also are given a report. At the department level, if a particular staff member has not regularly documented something that is required, the manager speaks with him or her.

If there is a problem systemwide education could remedy, the education department is notified so steps can be taken to teach staff.

"If we find something like handwriting legibility is a problem on all units, we do a big education push for it. If it is only a problem on one unit, a manager usually deals with it," says Ordelt.

Making sure documentation is complete is a process that includes system auditing as well as individual department auditing. The data from the audits are compiled into a report that is issued on a quarterly basis.

In addition to addressing problems identified by chart audits, Ordelt embraces opportunities to educate staff on the importance of documentation. She uses "Take Five," a short publication she distributes to staff to promote patient and family education, to provide a few lessons in good documentation practices.

In a three-part series, she told her readers the goal of education is to improve health outcomes by helping the caregiver learn how to care for the patient following discharge. Effective education is tailored to the patient or other caregiver by first conducting a learning needs assessment and documenting its results.

In one of her short articles she encouraged staff to determine each of the following:

  • What does the patient and family want or need to know?
  • How do they learn best?
  • How much do they know already?
  • What barriers are in the way, such as language, literacy, physical, emotional, or financial concerns?
  • Are they ready to learn?

In the second article she covered what needed to be included when documenting teaching interventions. Her recommendations were as follows:

  • Who was taught — the patient, parent, caregiver?
  • Was the learner determined ready to learn when assessed for learning readiness?
  • A short, concise list of the subject matter completed. For example, cast care, elevation; circulation and infection check; comfort measures and pain relief; positioning; and when to call the doctor.
  • The teaching methods used, such as verbal, written material, video, class, or hands-on demonstration.
  • Teaching materials used, such as the names of videos and teaching sheets.
  • Information on whether or not the learner understood the teaching with such comments as "verbalized understanding" or "demonstrated skill." If the evaluation of learning revealed a lack of understanding, then the need to repeat the information must be documented.
  • The signature and title of the person doing the teaching, as well as the date, must also be included.
  • Also important to document is any interventions taken to address learning barriers, such as the use of pictures when people can't read.

Sources

For more information on educating staff about documentation, contact:

  • Kathy Ordelt, RN-CPN, CRRN, patient and family education coordinator, Children's Healthcare of Atlanta, 1600 Tullie Circle, Atlanta, GA 30329. Phone: (404) 785-7839. Fax: (404) 785-7017. E-mail: Kathy.ordelt@choa.org.