Documentation prompts for learning assessment

Staff review status of teaching

Most patient education managers would agree that a system for documenting understanding of the teaching that takes place is important. Yet there is not a cookie-cutter method that institutions follow.

At DCH Regional Medical Center in Tuscaloosa, AL, educators can choose one of eight responses to document their evaluation of learning on an electronic interdisciplinary patient education record, says Susan Dashner, RN, MSN, patient education coordinator. These include applied knowledge; difficulty listening, restless; no evidence of learning; offered and refused teaching; performed independently; performed with supervision; requires reinforcement; and stated essential concepts. Evaluation of learning is a required field in documentation of patient education and they can't exit documentation without documenting the evaluation of learning, says Dashner.

At WellSpan Health in York, PA, an electronic system for documenting patient education is used in all areas except maternity, neonatal intensive care unit, and labor and delivery, which use paper forms to chart. When the electronic record was developed, the paper form was thorough and included target areas from The Joint Commission such as barriers to learning, preferred methods of learning, and evaluation of understanding, says Christine Hess, MEd, patient and family education coordinator.

The electronic form now has a field with checkboxes that address the evaluation of the learning for the patient and/or family. The choices are voiced understanding, demonstrates understanding, needs review, no evidence-learning, and by use of teach-back.

All staff members are able to view the ongoing documentation in the electronic record so they will see the current status of patient education when they are in the topic, says Hess. If there are areas needing to be addressed, they will receive the cue to fill them out, because some are mandatory.

The best method for assessing understanding is the teach-back method, Dashner says. Recently she put flyers on the units issuing a "teach-back" challenge. She asked staff to e-mail stories about how the teach-back method worked. Dashner promised a gift card for the best stories, which would be published in the nursing newsletter.

Documentation prompts assessment

While methods to assess understanding of teaching vary, the fact that it must be documented helps ensure it will be done.

Mary Szczepanik, RN, BSN, MS, a breast health specialist at OhioHealth Breast Health Institute in Columbus, says, "I think if a nurse has to document learning outcome, she is more inclined to assess it."

Szczepanik says there are many ways to assess understanding. These include asking probing or open-ended questions that require more than a yes or no answer, return demonstration, and describing scenarios that might occur and asking the learner 'what would you do if?' Another way to assess is to measure the ability to repeat back key information in their own words, such as reportable symptoms. Another way it so assess the patient's level of anxiety while teaching is taking place. All help the nurse decide whether teaching needs to be reinforced. Sometimes the reinforcement of teaching must be done with a follow-up phone call or, in more complicated cases, a home health nurse visit, says Szczepanik.

To make documentation of understanding simple OhioHealth has forms with three simple categories. These include: patient/family able to verbalize or demonstrate understanding; patient needs reinforcement; and not teachable at this time, which requires a note in the comments/plan section.

A combination of paper and electronic documentation is used at OhioHealth depending on the location.


For more information about the documentation of the evaluation of teaching, contact:

• Susan Dashner, RN, MSN, Patient Education Coordinator, DCH Regional Medical Center, 809 University Blvd., Tuscaloosa, AL 35401. Telephone: (205) 759 7154. E-mail:

• Christine Hess, MEd, Patient and Family Education Coordinator, WellSpan Health, 1135 S. Edgar St., Suite 101, York, PA 17403. Telephone: office: (717) 851-5859. E-mail:

• Mary Szczepanik, RN, BSN, MS, Breast Health Specialist, OhioHealth Breast Health Institute, 376 Blenheim Road, Columbus OH 43214. Telephone: (614) 268-3547. E-mail: