Perfecting the form and documentation process

Support good forms/guidelines with surveillance

Laura Gebers, BSN, RN, BC, health education coordinator at Deborah Heart and Lung Center in Browns Mills, NJ, has set in place several tools to help ensure that patient education is documented correctly.

The Interdisciplinary Patient Family Education Notes is a form which all disciplines who teach document. It is kept at the patient's bedside so any health care professional who walks into a patient's room has access to the notes for documentation at the time of education and care.

Also available are guidelines for documentation. These instructions provide details on the documentation process. For example, in the initial assessment the admitting nurse is instructed to check all learning preferences that apply to the patient or a family member.

Further details in the guidelines tell the nurse to ask how the patient or family member learns something new. Also, the nurse is instructed to write any additional information gained during the conversation.

In addition to the documentation notes and guidelines a surveillance form was created to determine if disciplines were documenting correctly. The tool used to monitor documentation has five categories and a section in which the surveyor can check yes, no or not available and make comments.

The categories are:

  • Tool initiated on admission.
  • Assessment complete.
  • Specific to patient's health care needs.
  • Updated as necessary.
  • RN, LPN signature and date legible.

Nurses on each unit are asked to do self-evaluations when their caseload is down in order to monitor documentation on a regular basis. However, in 2005 the chief nurse executive asked Gebers to evaluate documentation to determine if the numbers were as good as reported.

"Sure enough, my numbers were quite different from their numbers. When I went onto the units to evaluate I found there really needed to be quite a bit of improvement as far as the documentation process so that gave me an opportunity to do several things," explains Gebers.

Working one on one

When a staff member was not completing the patient education notes properly, Gebers would go to that person to review the documentation tool and guidelines and discuss his or her responsibility as far as assessment.

"By identifying the noncompliant staff member I was able to do just-in-time training where I could go right to where they were instead of scheduling a session or asking them to do a self-study packet," she explains.

Also Gebers checked to see if staff were implementing the proper documentation notes when a patient who came in for a same-day procedure was admitted to the hospital.

"The nurses needed to convert from a short form to a longer form and that was slipping through the cracks," says Gebers. To solve the problem new staff received a more thorough orientation on the difference between the forms and when to initiate the longer form. In addition, when patients could potentially be admitted to the hospital the long form was initiated upon check in for the same-day procedure.

Gebers also explained the rational behind the different areas of the documentation form and why they needed to be completed so that staff could do a better job of self-reporting. "They got to see I wasn't just writing down numbers trying to find fault with their work but trying to improve their work and help them to improve their work," explains Gebers.

Not only did it help them understand how to do their surveillance it helped them see how important it is to fill out certain sections on the form, says Gebers.

Also by highlighting areas that needed to be more completely filled in Gebers was able to get feedback on how to improve the tool so the next time the notes are revised she will include the recommendations staff made on how to improve the documentation process.

The monitoring was done weekly for three quarters. Gebers took a break but will begin another session of monitoring documentation to see if it is still being done correctly. She says it is important to have a presence on the units who acts as a reminder and someone to provide friendly encouragement and answer any questions they may have.

"It's okay if the numbers aren't good as long as we are able to find out what the problem is and take some corrective action," says Gebers.


For more information about the surveillance of the documentation of patient education contact:

  • Laura Gebers, BSN, RN, BC, PCS programs health education coordinator, Deborah Heart and Lung Center, 200 Trenton Road, Browns Mills, NJ 08015. Phone: (609) 893-1200, ext. 5258. E-mail: