Documentation confirms educational needs met according to plan of care

Communicate what was taught, how barriers were addressed

Similar to teaching, documentation must meet the needs of a patient. While some documentation is better than no documentation, more detail benefits the patient because it directs staff members on the status of the education process.

With documentation as a tool, staff can better determine what to do next, says Carol Ptasinski, RN, MSN, MBA, associate director of standards interpretation for the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.

A statement such as "medications reviewed with patient" is so vague other staff members wouldn't know what was covered; good documentation reflects what was done, including ways educational barriers were addressed, says Ptasinski.

The documentation sheet, which is part of the medical record, is a communication tool, agrees Kathy Ordelt, RN-CPN, CRRN, patient and family education coordinator at Children's Healthcare of Atlanta.

"The medical record is the only communication tool we have for that patient. Certainly word of mouth doesn't do it and shift-to-shift reports don't do it — those are all verbal and they get lost and jumbled up. The medical record is the only thing we have that completes the picture of that patient's care," says Ordelt.

To make her point, Ordelt tells staff to imagine walking into a room and trying to take care of a patient without a medical record. She tells them to imagine having to go back and retake a history and physical, redo all the tests that have been done, and redo all the consults from all the therapists and physicians and everyone who sees the patient because nothing was recorded. Staff always respond that they could not care for the patient.

"We document for a reason. The medical record is our guide for that patient's care; therefore what that translates into is safe, quality care for a patient when it is done properly. Documentation helps contribute to that safe, quality care," explains Ordelt.

Patient education is part of quality care, says Ordelt. Just as it is impossible to treat a patient properly without information about previous medical interventions, it is impossible to teach effectively without information on learning assessments, prior education, and the patient's comprehension of what already has been taught.

Teaching without regard to what patients have already learned or what they still need to know is unsafe, inconsistent, and frustrating for patients, says Ordelt.

Although it is helpful to create patient education documentation forms with check boxes and codes, such as "V" for "patient verbalizes understanding," in order to make the process quick and easy, some detail must be provided, says Ordelt.

For example, if a handout was used to educate the patient, it would not be enough to write "H" on the documentation sheet. The title of the resource would need to be written in the comment section as well so others would better understand what information was given.

While documenting that the education provided pertinent to a patient's plan of care is important, such as information about newly introduced medical equipment or supplies, it is not the only information needed.

To meet Joint Commission standards, documentation needs to reflect what was taught, when it was taught, whether the patient had any difficulties learning because of cultural, emotional, or cognitive barriers, and if the teaching was completed, says Jodi L. Eisenberg, CPHQ, CPMSM, program manager for accreditation and clinical compliance at Northwestern Memorial Hospital in Chicago.

When there are barriers to learning, a note on how they were addressed should be included. For example, when language is a barrier, stating that an interpreter was present during teaching would be appropriate.

If the teaching was not completed, there should be some sort of statement that the education needs to be reinforced or that the patient was unable to learn and the family was taught instead. The Joint Commission looks at evaluation of comprehension every time teaching occurs, and it needs to be documented, Eisenberg says.

Making a case for patient education

It is not only the Joint Commission that requires proof of comprehension. "While providing education is good, more important is that the patient was able to repeat back what was taught. That is the basics of informed consent. Unless the patient can repeat back what was taught, it isn't really consent and it is not education unless they get it; otherwise it is just people blabbering words at them," says Geri Amori, PhD, ARM, CPHRM, DFASHRM, senior director for education and professional development with the Risk Management and Patient Safety Institute in Lansing, MI.

Again, any documentation is better than no documentation, says Amori. However, when discussing what constitutes adequate documentation of patient education, the question is: Adequate for what? Adequate to be defensible in court or adequate to know it was done? To be defensible in court, the information documented must be as specific as can be provided. Anything that needs to be recalled in five years or more should be written down.

Documentation is important for defending a health care institution in litigation and ensuring that providers remember what happened, says Amori. And communication is important in preventing litigation in the first place, because it builds the relationship and the trust, she adds.

The literature indicates that when something goes wrong, medical lawsuits are triggered because patients feel there was a breakdown in communication. Patients believe they did not get adequate information or it was poorly presented. Also, they feel their perspective was dismissed.

Documentation that meets Joint Commission standards doesn't have to be as comprehensive as the records that would provide a good defense in court, as long as the health care institution has in place teaching protocols that are routinely followed and resources that are consistently given or used, says Ptasinski. As much detail as needed for patient education to be effectively completed is what is required.

"We would expect that if a patient was on a particular medication, he or she would be educated on that medication. We would say, 'Show us where you documented the patient received education,' and then see what process is in place," says Ptasinski.

With the new tracer methodology of surveying, the Joint Commission surveyor would interview staff and the patient to make sure an adequate educational process was in place. To ensure the same educational process was followed for each patient, the surveyor might trace another patient.

Adequate documentation for the Joint Commission means that any education needed as part of a patient's plan of care be documented. Documentation can be general as long as the resources are available that show the patient's educational needs were met, says Eisenberg.

"Our rule of thumb is that if it wasn't documented, it wasn't done. However, if you put down everything you educated a patient on, your medical records would weigh 50 pounds," she explains.

The expectation is not verbatim documentation but to cover the four basics: what was taught, when the teaching took place, the educational barriers, and whether the teaching was completed. If this information is included in the documentation of patient education, an institution should be covered from a regulatory standpoint as well as a legal one, says Eisenberg.

Sources

For more information on documentation of patient education, contact:

  • Geri Amori, PhD, ARM, CPHRM, DFASHRM, senior director for education and professional development, Risk Management and Patient Safety Institute, Lansing, MI. Phone: (802) 985-5458. E-mail: gamori@rmpsi.com. Web site: www.rmpsi.com.
  • Jodi L. Eisenberg, CPHQ, CPMSM, program manager, accreditation & clinical compliance, Northwestern Memorial Hospital, 676 N. St. Clair, Suite 700, Chicago, IL 60611. Phone: (312) 926-5705. Fax: (312) 926-8734. E-mail: jeisenbe@nmh.org.
  • 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.
  • Carol Ptasinski, RN, MSN, MBA, associate director of standards interpretation, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5000. E-mail: cptasinski@jcaho.org.